Record number:
420
Adverse Occurrence type:
MPHO Type:
Time to detection:
19 days
Alerting signals, symptoms, evidence of occurrence:
A 29 year old woman received a frozen non-irradiated patellar tendon, bone-tendon-bone allograft to replace a damaged anterier cruciate ligament. Nineteen days later she developed septic arthritis, 39.4C fever. Klebsiella oxytoca and Hafnia alvei were cultured from the knee aspirate. The same species of organisms and Serratia liquefaciens were cultured from the donor allografts during tissue processing. Although the same bacteria were found on the tendons before processing, the tissue bank erroneously failed to perform terminal gamma irradiation as is required by their procedures.
Demonstration of imputability or root cause:
Level 4. Certain. Same bacteria on tendon before processing and in recipient. Although the same bacteria were found on the tendons before processing, the tissue bank erroneously failed to perform terminal gamma irradiation as is required by their procedures.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
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