Error: Kidney Is Transplanted Into The Wrong Patient

Feb 22, 2011
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There are errors and then there are epic errors. USC University Hospital in Los Angeles usually transplants two kidneys per week, but it stopped all kidney transplants after a kidney was accidentally transplanted into the wrong patient. The mix-up is being chalked up to a “process error.”

A mismatched organ can prove lethal, but the patient survived the error. The LA Times reported the donor’s blood type was the universally accepted O. The intended recipient for that kidney did receive a kidney a few days later. The error happened after two kidneys, from separate donors, arrived at the transplant center around the same time on Jan. 29. Usually, after a kidney is removed from a donor, it’s secured in a plastic container with a screw-on lid. That container is labeled with an identification number, and is then placed inside three sterile plastic bags, which are placed on ice in another container.

Dr. Goran Klintmalm, a veteran surgeon at Baylor Regional Transplant Institute in Dallas, said that such a mistake is almost inconceivable. “The safeguards are very substantial,” he said. “I can’t even imagine how this mistake could have happened.”

“The nurses in the operating room and the surgeon must check for the ID number on the kidney and compare that with the patient ID number,” Klintmalm said. “It is the operating room surgeon’s responsibility to make sure the numbers match. You sign forms before you start the surgery.”

Thomas Mone, the chief executive of OneLegacy which coordinated the organ’s transfer to the hospital, said, “Our packaging and documentation was accurate. Presumably this was ‘human error’ at the hospital.”

USC hospital officials said, “Prior to surgery, the transplanted kidney was determined to have an appropriate blood type for the patient who received it.” Dr. Cynthia Herrington, medical director of the USC Transplant Institute, said the error was the result of human error and process failure, noting “our process of matching the donor identification number to the recipient’s name failed.”

The United Network for Organ Sharing (UNOS) is investigating the misplaced transplant at USC University Hospital, according to OneLegacy spokeswoman Elena de la Cruz. But UNOS cannot confirm if USC is under investigation; if so it would be considered “under confidential medical peer review.” The UNOS investigation outcome may not become public knowledge if the agency “deems adequate the resolution and corrective actions of the hospital.”

This is not the first time an organ was transplanted into the wrong patient. In 2003, Duke University surgeons accidentally gave the wrong heart and lungs to a 17-year-old girl which resulted in her death. In 2006, a Times investigation discovered that nearly “a fifth of federally funded transplant programs failed to meet the government’s minimum standards for patient survival or performed too few operations to ensure competency. And, despite repeated lapses, federal overseers allowed 488 heart, liver and lung transplant centers to continue operating.”

California Department of Public Health spokesman Al Lundeen said the state is also investigating the private research and teaching hospital staffed by faculty from the USC Keck School of Medicine.

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Author: Tessa



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