Adverse Occurrence type:
Alerting signals, symptoms, evidence of occurrence:
A male patient with acute myeloid leukaemia received a pooled platelet preparation. The patient collapsed after two-thirds of the contents had been transfused. Clostridium perfringens was isolated from the platelet bag within 18 h of the acute event. The patient died 4 days after the platelets were transfused.
Demonstration of imputability or root cause:
On subsequent investigation, C. perfringens type A serotype PS68, PS80 (identical to that found in the platelet bag) was cultured from the venepuncture site of the arm of one of the donors who contributed to the platelet pool.
McDonald, C. P., Hartley, S., Orchard, K., Hughes, G., Brett, M. M., Hewitt, P. E., and Barbara, J. A.(1998). Fatal Clostridium perfringens sepsis from a pooled platelet transfusion. Transfus Med 8(1): 19-22.