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HRC Memos-Blood Supply
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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explain that hospital officials decided themselves -- after a review indicating that their computer tracking system was out of date -- to stop collecting blood, update their system, and retrain their technicians.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