A friend of mine was an ear, nose and throat surgeon at the Massachusetts Eye and Ear Infirmary while I worked at Mass General. He performed a lot of tonsillectomies on eight- to ten-year-old boys and would often request coagulation tests to ensure that they would not have bleeding issues after the procedure. He said that he often found a prolonged PTT.
When he received an abnormal PTT result, he had two choices: i) call a hematology consult, which would usually take two days, or ii) transfuse two units of plasma. Most of the time, he opted to transfuse so that he could complete the procedure and discharge the child. Unfortunately, he was doing this between 1981 and 1984 – a time when one in every 20 bags of fresh frozen plasma was infected with either HIV or hepatitis C. We didn’t know that at the time, of course – but these children were put at risk because their surgeon didn’t know what test to order. My friend admitted to me that he was overjoyed when, in 1995, we began providing interpretations along with our test results. But then he considered how many people he had unnecessarily transfused. His “error” didn’t come to light when his patients were eight years old, but many years later – when these children had become young adults and needed liver transplants or received diagnoses that would change and abbreviate their lives.
And yet, nobody (until now) has pointed out the root cause of this problem – the fact that somebody didn’t know what laboratory test to pick because of an inability to interpret a prolonged PTT. In short, a major diagnostic error led to patient deaths. I wish I could say that this was the only example of such an error but, unfortunately, it’s just one of many.
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