Blood transfusion mix-up: Two nurses of Aundh District Hospital suspended

Pune: Taking cognizance of a medical error regarding the wrong blood transfusion of two elderly patients during treatment at the Aundh District Hospital (ADH), the Maharashtra health department on Tuesday suspended two nurses with immediate effect and initiated an investigation into the matter.  

The action was taken as per the Maharashtra Civil Services (Discipline and Appeal) Rules 1979 after a preliminary investigation conducted by the hospital administration found the two nurses responsible for the transfusion of two patients with the wrong blood groups on Saturday due to a mix-up of blood pouches.   

In addition, the enquiry committee in their investigation also discovered that the mix-up was a result of distractions stemming from engaging in a conversation on a mobile phone.  

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According to health officials, the nurses allegedly administered two separate blood groups to two wrong patients identified as 58-year-old Dattu Sonaji Sonawane and 73-year-old Dagdu Kamble both admitted at ward number 204 of ADH. 

The two patients admitted for anaemia were lying on beds adjacent to each other. One of them has a blood group of A+ and the other B+. The patient Sonawane required blood from the ‘A positive’ group and was given ‘B positive’ blood and Kamble required blood from the ‘B positive’ group and was given ‘A positive’ blood. 

Therefore, the wrong blood transfusion resulted in their health rapidly deteriorating prompting the officials to transfer them to the ICU for better treatment after one of the patients’ relatives noticed the blood pouch with the wrong name. 

Meanwhile, the conditions of the patients are stable now and they will soon be moved to the general ward. 

Speaking to the  Pune Mirror, civil surgeon Nagnath Yempelle said, “Both nurses have been suspended with immediate effect. Their actions resulted in a significant error and endangered the lives of both patients. Consequently, we had to shift the patients to the intensive care unit (ICU). Fortunately, both the patients are now recovering well.”

Providing details, he said, “Dattu Sonaji Sonawane and Dagdu Kamble were hospitalised for pneumonia. Both were suffering from breathing difficulties, edema (swelling) in both lower limbs, and other issues. Since their haemoglobin level was lower than normal, both required immediate blood transfusion.

Dr Kiran Khalate, who was the on-duty doctor, directed the administration of blood transfusions to the patients by the nursing staff. However, it seems that there was a mix-up with the blood bags, leading to a serious complication known as a hemolytic transfusion reaction.”

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