![]() ![]() Hospital officials also say they have fixed most problems at the blood bank, and that they have shut down at least temporarily the part of the blood bank that draws, tests and labels blood from donors.Īmong the problems county and federal investigators said they found: In the negotiations aimed at settling the case, the subject of problems at the blood bank did not come up, and the county officially will not have to admit wrongdoing, or even negligence, said Mark Grayson, Clemons’ lawyer. ![]() Nor was she told that she could have given her own blood in the weeks before her scheduled operation, a safety precaution strongly encouraged by most hospitals, she alleges in the lawsuit she filed against the hospital and county. This has to stop.”īut Clemons, 44, didn’t know any of that. “Our laboratory,” Howard warned, “remains in the dark ages as far as staffing and progress in the transfusion service is concerned. It was not up to speed, she said, with the many regulatory changes that had occurred in the complex field of blood safety, especially with the increasing use of computers and new technology. Seven months earlier, blood bank supervisor Novella Howard complained in a letter to her supervisors that the hospital’s overall transfusion service was far too understaffed for such a busy trauma center. Warnings, however, were sounded well before Clemons’ ill-fated transfusion. Some hospital officials also had changed the workings of the blood bank computer records to hide the HIV status of blood to protect donor confidentiality, yet they never told many of the employees who needed to know-including the nurse who let the blood go, county documents show. Another unit, later determined to be a false positive, was used in a transfusion for another patient through the same combination of human error and lack of safeguards, county investigators found. The head of the blood bank and other management staff, for instance, were “unaware” of many basic regulations and safety guidelines and they did not have on hand most of the appropriate-and legally required-rules, regulations, guidelines, federal informational updates and reference materials “designed to prevent catastrophic errors such as that which occurred,” the county report concluded.Īnd Clemons was not the only person to receive blood that had tested positive for HIV in June 1994, at King/Drew. “There is no question but that this program was seriously deficient, with chronic, systemic operational problems.” “I’ve never seen anything like it,” said Fred Leaf, chief investigator with the health department’s inspection and audit division. The blood bank suffered from severe understaffing, inadequate training of employees, poor management and oversight, miscommunication and bickering among leadership and failure to adhere to some of the most basic safety requirements, according to an investigative report prepared by the Department of Health Services and other documents, including Civil Service Commission records. But the county’s own documents, as well as federal inspection and investigatory reports, paint a picture of a blood services system so riddled with problems that Clemons’ receipt of the HIV-tainted blood was, in effect, a tragedy waiting to happen-and one that county officials were warned about well in advance.Ī host of required safeguards designed to protect Clemons and others from the accidental release of tainted blood had been overlooked or circumvented or were not in place at all, according to citations from the federal Food and Drug Administration and the results of a county Department of Health Services investigation done in the wake of Clemons’ transfusion. ![]()
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