Record number:
396
Adverse Occurrence type:
MPHO Type:
Time to detection:
10 days
Alerting signals, symptoms, evidence of occurrence:
A 56 year old male received a frozen non-irradiated patellar tendon, bone-tendon-bone allograft to replace a damaged anterier cruciate ligament. Ten days after surgery he developed purulent drainage growing Citrobacter workmanii/youngae, Streptococcus Grp B. After lengthy treatment the graft was removed and later the patient needed total knee arthroplasty. Although the same bacteria were found on the tendons before processing, the tissue bank erroneously failed to perform terminal gamma irradiation as is required by their procedures.
Demonstration of imputability or root cause:
Level 4. Certain. Same bacteria on tendon before processing and in recipient. Although the same bacteria were found on the tendons before processing, the tissue bank erroneously failed to perform terminal gamma irradiation as is required by their procedures.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
Suggest references:
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