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Labeling Error to Blame for Hospital’s Release of Coronavirus Patient


The patient, one of hundreds evacuated by the U.S. from China, was released from a San Diego hospital to quarantine before the mistake was discovered, health officials said.

A woman sick from the coronavirus was released from a San Diego hospital this week after a labeling error on samples to be tested for the virus led officials to incorrectly indicate that she was not infected, federal authorities said on Tuesday.

The samples had not even made it into the Centers for Disease Control and Prevention’s laboratory when the agency mistakenly indicated to officials at the hospital that the results were negative.

The woman, who was among hundreds recently evacuated to the United States from China and under quarantine at a military base, was erroneously discharged from the hospital and sent back to the base because of the error.

She was among three quarantined evacuees at Marine Corps Air Station Miramar in San Diego whose samples, likely oral or nasal swabs, were not admitted to the laboratory because of a label mix-up and went untested, said Kristen Nordlund, a spokeswoman for the C.D.C. It was unclear exactly what the labeling error was and which agency had been responsible.

A spokeswoman for the hospital, the University of California San Diego Health, said there had been miscommunication over how to identify patients under evaluation, to whom the hospital had assigned pseudonyms to protect their privacy.

The coronavirus epidemic has left more than a thousand people dead in China and has sickened tens of thousands of others. As the crisis continued to unfold, about 850 people, most of them Americans, have been evacuated from Wuhan, China, where the outbreak began, to five military bases in the United States.

With a rare federal quarantine mandated for people arriving from Wuhan, the labeling error raised concerns among some who were being kept with the coronavirus patient at Marine Corps Air Station Miramar, and prompted the authorities to announce new procedures to avoid testing mistakes.

“It caused quite a commotion,” said John McGory, who had taught English in Wuhan for six years and is among about 230 people being held on the San Diego base.

Officials said that despite the early release of the patient, people under quarantine at the base would not need to restart the 14-day quarantine period, but those at the base remained skeptical, Mr. McGory said.

He and others learned of the labeling mistake from news reports before they were told by staff members on the base, he said, angering some who took their frustration out on C.D.C. officials during a meeting on the base on Monday night.

The episode began last week when three people who had been quarantined at the San Diego base showed symptoms of illness and were taken to the hospital not long after they arrived in the United States.

A miscommunication between C.D.C. officials led the agency to tell the hospital that all the patients had tested negative even though three of the samples had not been tested, Dr. Christopher R. Braden, a medical epidemiologist with the C.D.C., said at a news conference on Tuesday evening. Thinking that the three were clear of the virus, the hospital sent the patients back to the base to complete the 14-day quarantine period with scores of others.

The error was discovered as the three people, wearing masks, were riding in a van back to the base on Sunday. Their specimens, officials realized, had never been analyzed.

“Of course, as luck would have it, there was one of those tests that came back positive,” Dr. Braden said.

Rather than return the three to the hospital, health officials decided to proceed to the base, telling the patients to isolate themselves in their rooms, officials said.

The test results came back on Monday morning. One of the three people — identified only by her gender — was positive for the virus and was rushed back to the hospital. She was being treated there and was doing well, with just a minor cough, Dr. Braden said.

Thomas Skinner, a spokesman for the C.D.C. who is on the base, said the woman had been isolated in a room on the base for about 16 to 18 hours. Health officials were working to determine whom the patient had interacted with during that period, he said.

As word of the illness — and the labeling error — spread among others in quarantine on the base, some said they were concerned. At least one man, who declined to be identified by name, said he had questions about whether enough people were being tested, whether common areas were being disinfected and whether health officials were being transparent enough with those under quarantine.

The C.D.C. said laboratory staff members were working to prevent such errors.

Another person under quarantine was also being tested at the San Diego hospital on Monday, officials said. Nine people from the Miramar base have been tested for the virus; five of those tests have come back negative, three are pending, and one — the woman’s — was positive. She began having symptoms the morning after she arrived at the base by plane.

In total, 13 people in the United States have tested positive for the virus across six states.

Local health officials in Riverside County, Calif., said on Tuesday that 195 people from the first government evacuation flight, which left Wuhan on Jan. 29, were to be released from quarantine at March Air Reserve Base by Wednesday. All were found to be free of the virus during two weeks in quarantine.

Source: The New York Times

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CMLF News Issue #7
27th January 2016