Record number:
1029
Adverse Occurrence type:
MPHO Type:
Time to detection:
immediate post-operative period (1-2 hours)
Alerting signals, symptoms, evidence of occurrence:
A 60-year-old woman undergoing surgery died from endotoxic shock and DIC after receiving a 19-day-old unit of optimal additive red-cell concentrate found contaminated with Serratia liquefaciens.
Demonstration of imputability or root cause:
S. liquefaciens cultured from patient and red cell unit: indistinguishable pathogen from the isolates from the blood packs, the recipient's ante mortem blood sample and the post mortem blood cultures. Two weeks after the recipient died, the donor appeared entirely well and gave no history of any recent illness at the clinical assessment. No source of the contamination could be found.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
References:
Suggest references:
Kuehnert, M.J., Roth, V.R., Haley, N.R., Gregory, K.R., Elder, K.V., Schreiber, G.B., Arduino, M.J., Holt, S.C., Carson, L.A., Banerjee, S.N. and Jarvis, W.R. (2001). Transfusion-transmitted bacterial infection in the United States, 1998 through 2000. Transfsuion 41(12): 1493 -9
Boulton, F.E., Chapman, S.T., Walsh, T.H. (1998). Fatal reaction to transfusion of red-cell concentrate contaminated with Serratia liquefaciens. Transfus Med 8(1): 15-18.