The woman who alerted health officials to questionable HIV laboratory tests
at Maryland General Hospital - and is now infected with HIV herself - says
she's convinced that problems at the health care facility are more serious and
pervasive than inspectors have discovered.
Kristin S. Turner, a former lab worker at the hospital, said she fears
there could have been thousands of questionable tests for HIV and hepatitis,
instead of the hundreds officials have identified in an inspection of the
245-bed health care facility.
It was a complaint from Turner late last year that triggered the initial
inquiry by the state Office of Health Care Quality.
In an interview at her attorney's office yesterday, Turner said her life
has been irreversibly changed by contracting HIV and hepatitis - the result,
she contends, of being showered with infected blood serum when the hospital's
testing equipment malfunctioned.
"It was the worst nightmare of every medical worker," she said softly but
firmly. "Everything about my life has changed. It tore it completely apart,
turned it upside down."
Turner, 32, filed a lawsuit last week in Baltimore Circuit Court against
Maryland General and Adaltis USA Inc., the manufacturer of the blood analyzer.
Hospital officials released a three-paragraph statement last night in which
they announced hiring PCS Laboratory Solutions of Midway, Utah, to provide
immediate lab management support, perform a comprehensive review of the
hospital's lab and make any changes. Officials also stated that they would
expand efforts to "contact everyone who should be retested." Lee Kennedy, a
hospital spokesman, refused further comment.
Representatives of Adaltis did not return calls seeking comment on Turner's
Meanwhile, state and federal inspectors, along with officials of a private
accreditation agency, yesterday continued an unannounced review of the
hospital that began Tuesday. Citing the continuing inspection, state health
officials also declined to comment on Turner's statements.
U.S. Rep. Elijah E. Cummings, the Maryland Democrat who represents the
district where Maryland General is located, said yesterday that a
congressional hearing will be held in May to look into the testing equipment
and its use.
Officials at Maryland General - an affiliate of the University of Maryland
Health System - have acknowledged that 460 suspect test results were sent to
patients over a 14-month period ending in August last year.
According to a state inspection report, hospital laboratory personnel
manipulated and eliminated machine readings showing that recently completed
blood tests might be inaccurate and should be discarded. The hospital has
begun efforts to find and retest all patients who received the suspect
Hospital officials say they're cooperating with the review by the state
Office of Health Care Quality, the federal Centers for Medicare and Medicaid
Services and the Joint Commission on the Accreditation of Healthcare
In yesterday's interview, Turner said she noticed problems with the
hospital's blood testing machine, known as a Labotech, shortly after going to
work in the hospital laboratory in the fall of 2002.
"Every run had different errors. Three of every five tests were wrong. The
machine failed its own self test," Turner said. She added that the machine
would often skip over required steps in the testing process: "You'd never even
know unless you were standing there watching. None of the techs had confidence
in the machine."
Turner said complaints about the equipment became so frequent that the
manufacturer at one point sent a second machine as a backup. But the problems
continued, she said.
She said the complaints were registered with James Stewart, the
laboratory's administrative director. Stewart, named as a defendant in
Turner's lawsuit, did not respond to requests for comment.
Turner said the machine was used two to three times a week to process about
60 patient samples for HIV or hepatitis. She estimated that the number of
tests performed before the hospital stopped using the equipment in August was
"in the thousands."
The incident that led to her infection occurred on March 12, 2003, Turner
said, when the machine was processing a batch of samples and its computer
screen indicated a problem that required her to open the case.
After checking the positioning of the equipment, Turner said, she pushed a
button to continue the test. Shortly afterward, she said, the machine
malfunctioned - an arm slammed down on the test-tube samples, smashing the
glass and splattering her with blood.
Turner said she was wearing protective goggles and a mask, but the
HIV-infected blood dripped under the goggles and "under my nose and pretty
much all over."
When she couldn't find a supervisor, Turner said, she sought help from
fellow lab workers, then washed away the blood and went to the emergency room
for treatment. She said tests performed on her that day were negative for HIV
"It was very scary," she said recounting the scene.
Because of the exposure, Turner said, she immediately began taking
medications prescribed for those who have been exposed to the viruses.
In June, she said, she developed a high fever and became "really sick. It
was like a very bad case of the flu."
She said she was admitted to the hospital for about a week, at which time
tests showed she was infected with HIV and hepatitis.
Turner is now taking 12 pills a day - ten in the morning and two at night -
to fight the infection. "Some of the meds are horrible. The HIV medicines are
particularly virulent," she said.
But the medications are only part of a painful adjustment. Some longtime
friends "just disappeared," she declared.
It was especially hard to tell her family. When one has HIV, Turner said,
"It doesn't matter how you got it."
"Every single minute of every day is affected by what happened that day.
People walk away from me," she added.
She said that shortly after she moved into a new apartment building, word
got out that she was HIV positive, and a flier was distributed to the
residents informing them of her condition. She now lives out of state.
Turner said that after she got no response to her initial complaints to the
hospital about the inaccurate lab testing, she sent a detailed letter to city
health officials. They, in turn, passed the information on to state regulators
who began a limited inspection in January. That in turn led to the wider
investigation now under way.
"They [hospital officials] knew the community was at risk, but they didn't
do anything," she said, explaining why she turned to the state. "I didn't get
Turner said she was especially concerned because sending out potentially
inaccurate test results put not only patients at risk, but also the people
with whom they came in contact.
"I wish the hospital had done the right thing on their own. I wish we
didn't have to be here right now. This really didn't have to happen," she
said. "The community needs to be able to trust the results from their
hospital. That trust has been completely stomped on and broken."