Thursday, January 16, 2014

H.I.V.-Positive Person, Told Otherwise, Is Being Sought



For the last six weeks, Walter Reed National Military Medical Center has been engaged in a highly unusual effort to identify an individual who is H.I.V. positive but was wrongly informed that he or she was H.I.V. negative after a mix-up of blood samples taken at the hospital.
The mistake occurred in late October when the military’s flagship hospital, in Bethesda, Md., sent 150 blood samples to a contract laboratory for analysis. One sample tested positive for H.I.V., hospital officials said, but it was wrongly labeled with the name of a patient who subsequent tests showed was not infected.
A hunt is now underway to identify the infected person, who may be in need of treatment and could be unknowingly infecting others through unprotected sex or the sharing of needles.
Hospitals are supposed to have strict safeguards to ensure the integrity of laboratory specimens because the consequences to patients are potentially life-threatening. Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University, said the episode raised questions about the adequacy of the hospital’s procedures. “How sure are they that this didn’t happen before?” he asked.
Walter Reed officials narrowed their search from the initial group of 150 people whose blood samples were shipped to the laboratory to 72 people who shared the same blood type as the unknown infected person. On Dec. 2, the hospital sent those people certified letters asking them to return for new tests. Sixty-three people have responded, and 50 of them have been retested so far, according to Sandy Dean, the hospital spokeswoman.
Nine people have not been heard from. “Email, phone, letters: We are trying every way we can to get in touch with those folks,” Ms. Dean said in an interview.
The hospital acknowledged the error after The New York Times posed a set of questions about the case. In a statement, the hospital said identifying the H.I.V.-positive person and “maintaining full transparency throughout this process” remained its highest priority.
Ms. Dean said she could not give more details about how the mistake occurred because it was under investigation by the Navy Bloodborne Infection Management Center, which oversees the military’s policies on H.I.V. and hepatitis. She said no similar episode had occurred since late 2011, when the Walter Reed Army Medical Center and the Bethesda Naval Hospital were combined to form the national medical center.
Active-duty service members are required to be tested for H.I.V. every two years, but they made up only part of the group of 150, Ms. Dean said. She declined to characterize who else was in the group.
Ms. Dean said the infected patient’s blood was drawn on Oct. 23. On Nov. 6, the person who was misidentified as H.I.V. positive was retested, a routine procedure in H.I.V. cases. Both that test and a follow-up test were negative. The initial blood sample was retested, confirming that an unknown person was H.I.V. positive.
Ms. Dean said the Joint Commission, an independent, nonprofit organization that accredits hospitals, had been notified of the problem. 

 http://www.nytimes.com/

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