MD Anderson Under Federal Oversight After Blood Transfusion

The Centers for Medicare and Medicaid Services noted the deficiencies earlier this month in letters and reports issued following investigations conducted at MD Anderson after the cancer center reported the event in December. The center is currently developing plans of corrective action, which will be submitted next week.

“These deficiencies have been determined to be of such a serious nature as to substantially limit your hospital’s capacity to render adequate care,” one of the letters said.

MD Anderson officials would not say whether the event was a patient death.

Details of the deficiencies are contained in the reports, which are not yet public. The letters, which are public, provide only a general summary.

The notice came as a shock because of MD Anderson’s sterling reputation, highlighted by its routine No. 1 rankings in U.S. News & World Report’s annual survey of best hospitals. Patient care and safety are key components of the magazine’s rankings.

The letters are similar to ones the agency sent earlier this year to Baylor St. Luke’s Medical Center following investigations there after an emergency room patient died as a result of a transfusion of the wrong blood type, given because of a labeling error. The medical center disclosed the death to the Chronicle before the CMS letter became public.

MD Anderson officials said the cancer center’s blood transfusion adverse event did not involve mislabeling.

Blood transfusions are a staple of a hospital’s cancer care. MD Anderson transfuses as many as 200,000 blood products annually.

“We have policies and procedures in place to protect our patients,” MD Anderson officials e-mailed the Chronicle. “However, in rare instances, severe reactions occur. The transfusion of blood and blood products from human to human carries inherent risks — from mild to severe.”

The state and federal investigations revealed serious problems related to nursing care, laboratory services, patient rights, quality assurance and performance issues, and institutional oversight. The reports detailing the deficiencies — one involving the hospital, the other its clinical laboratory — will be made public after MD Anderson submits the corrective actions plan.

Houston Chronicle
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