A Hollywood hospital was fined $25,000 by the state of California after nurses failed to follow blood transfusion protocol and a patient died as a result.
A state Department of Public Health investigation found that in October a patient at Hollywood Presbyterian Medical Center was given a blood transfusion that wasn't needed and was the wrong blood type.
Two nurses failed to follow the hospital's policy for blood transfusions, allowing a blood transfusion to go on for 15 minutes before realizing the error. According to the state investigation, the nurse who discovered the incorrect transfusion did not report the error to a doctor.
Instead, the transfusion was discontinued and the tubing was changed on the blood bag and given to the correct patient, the investigation said.
About an hour later, another staffer noticed the patient was cyanotic, or turning blue, and having difficulty breathing. A doctor was informed by phone about an hour and a half after the error.
The patient, who was admitted to the hospital for renal disease, died hours later after suffering a hemolytic reaction, which occurs when incompatible blood types mingle. The name and age of the patient were not released.
A statement from the hospital Wednesday said the two nurses involved have resigned after initially being suspended and the hospital followed state law by reporting the incident immediately. Their supervisor remains at the hospital.
"Everyone at the hospital deeply regrets this incident and the death that it caused," hospital Chief Executive Jeff Nelson said in a statement.
The hospital has taken steps to improve the efficacy and understanding of their policies, Nelson said. The statement did not elaborate on what steps were taken.
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