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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