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HRC Memos-Blood Supply
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HRC Memos-Blood Supply
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Records of the First Lady's Office (Clinton Administration)
Jennifer Klein's Files
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HR C has seen
TO:
Hillary Rodham Clinton
FROM:
Jennifer Klein j.n.
DATE:
2/26/98
RE:
Blood Supply at National Naval Medical Center
Pam said that you had asked us to follow up on the Washington Post article about
problems with the blood supply at National Naval Medical Center at Bethesda. I spoke to both
the Deputy Commander at the hospital and officials at the Food and Drug Administration
responsible for investigating instances like this one. Apparently, technicians mistakenly
removed a punctured, unrefrigerated bag of blood from the autoclave, where it had been left to be
destroyed, and returned it to the blood bank, where it was used for a transfusion for an infant in
the neonatal intensive care unit. The technicians have been terminated.
Fortunately, the baby is fine, and the instance does not seem to be representative of larger
problems. While the Post refers to this as "the latest embarrassment at a blood bank
troubled
by mishaps and confusion the FDA assured me that a thorough FDA review has found no
other problems at Bethesda. FDA did explain that hospital officials decided themselves -- after a
review indicating that their computer tracking system was out of date -- to stop collecting blood,
update their system, and retrain their technicians. While the FDA has no reason to believe there
are ongoing problems, they will closely monitor the hospital's blood bank.
A Naval I ospi al, "Wo Lose, obs
After Boy Given Unusable Blood
By Avram Goldstein
determined that he had not contracted any
Washington Post Staff Writer
infections, officials said.
It was the latest embarrassment at a blood
Two supervisors in the blood bank at National
bank that has been SO troubled by mishaps and
Naval Medical Center in Bethesda have been
confusion that hospital administrators suspended
removed from their jobs for allowing blood that
donations there three months ago. Inspectors
should have been destroyed to be transfused into
from the Food and Drug Administration said that
a two-pound infant in the neonatal intensive care
sloppy management practices and rampant book-
unit.
keeping errors allowed suspect blood into the
The Jan. 28 transfusion was interrupted when
military blood supply, including units not thor-
a technician discovered the mistake, but the
oughly tested for the AIDS virus.
5-week-old boy had already received 11 cubic
In this case, the blood was slated for destruc
centimeters of blood-about one-third of an
tion after technicians found a perforation in the
ounce. Cameron Howell, the son of an Air Force
plastic bag used to collect and store the blood,
staff sergeant stationed in South Korea, was put
then left it unrefrigerated overnight in an area
on antibiotics as a precaution, and lab tests
See BLOOD, C10, Col. 5
closed parts of the rocomoke River, the
Two Blood Bank Supervisors Fired
BLOOD, From C1
"These were people who made deci-
sions or judgments who should have
designated for unusable blood. Donor
known better," he said. Because they
blood that is exposed to air is unusable
work for a contractor, the employees
because of the risk of bacterial or viral
have no appeal rights.
contamination.
But the company they work for, Sheri-
But because of a complex series of
kon Inc., of Chantilly, a firm that pro-
missteps involving several people, the
vides the services of 1,000 engineering
Navy said, the blood wound up back in
and medical personnel across the coun-
the supply pipeline.
try, said that the two employees were
"I was upset at first, but things
not to blame and that they remain on the
worked out," said Cameron's mother,
Sherikon payroll, though not at the
Kim Howell, who lives at Andrews Air
hospital.
Force Base with her three other chil-
"Our people did not have any part in
dren. "They kept me up on everything
causing the blood to be used or any part
that was going on."
of the transfusion process," said Sheri-
When Cameron was born three
kon President Edward R. Fernandez.
months prematurely on Dec. 23, he
"We instructed a technician to put the
weighed 1 pound 8 ounces. Today, he
bag in the unusable container for de-
weighs about 2 pounds 13 ounces,
struction. That was the last involvement
Howell said. He has battled lung prob-
we had with that blood."
lems and recently underwent intestinal
It isn't clear when blood donations
surgery, but the outlook is good for the
will resume at the hospital, also known
boy's release next month from the
as Bethesda Naval Hospital, although
hospital, she said.
officials said it will not happen until the
A hospital spokesman, Cmdr. Ryland
60 members of the blood bank staff are
Dodge, said the case did not reflect any
retrained. In the meantime, the hospital
larger, systemic problems. "However,
is getting its blood supply from other
it's a serious occurrence, and we believe
blood banks.
we are taking the appropriate actions to
Separately, the hospital filed charges
prevent it in the future," he said.
in December against a civilian Defense
Dodge said two civilian contract em-
Department employee who worksin the
ployees who were supervisors in the
blood bank for allegedly mishandling
blood bank were "terminated." He was
files and mislabeling units of blood. The
unable to release their names yesterday.
employee is fighting the action.
PHOTOCOPY
PRESERVATION