Duke transplant error spurs hospitals, risk managers to reassess programs
Transplant trouble reveals shared weaknesses
Hospitals across the country are taking a hard look at their processes to spot weaknesses similar to those at Duke University Hospital, where a patient died because of a lack of redundancy in the system for matching donated organs.
The lessons from Duke, in Durham, NC, stretch far beyond organ transplants, says Doug Campbell, assistant vice president of operations and risk management at Robert Wood Johnson (RWJ) University Hospital in New Brunswick, NJ. Campbell’s hospital responded quickly to the Duke incident by revising its own transplant system, adding another redundant step in which clinicians will verify the blood-type match between the donor organ and the recipient. He suggests that risk managers consider this a good reason to take a second look at many similar processes beyond just transplant surgery.
The fundamental error appears to be one that could happen in a wide range of clinical scenarios, he says, so don’t assume your systems are adequate.
"You need to take a hard look at this procedure and any other procedure with the potential for a catastrophic mix-up like this, like site verification," Campbell says. "Assume that your steps aren’t good enough, and challenge yourself to make them better."
Fifth protocol added as safety measure
Duke’s nightmare began when a surgeon misinterpreted a message from the organ-donor bank. The surgeon mistakenly thought he was being told the organ was a blood-type match, when in fact the donor bank was only informing him that the heart and lungs were available for his patient. That error went uncorrected until the surgery was under way, apparently because the Duke system did not have adequate steps in place to require checking the blood type of donated organs.
The risk manager at Duke did not respond to repeated requests for an interview, but the hospital has released several statements describing the incident and the results of its root-cause analysis. Lack of redundancy was the critical failure, the hospital reports, so Duke has added "multiple confirmations of donor match by members of the care team before the transplantation process begins and improved communications between Duke and the organ procurement organization," according to a statement from William Fulkerson, MD, CEO of Duke University Hospital.
Transplant programs across the country responded to news of the event in much the same way, says Ronald Freudenberger, MD, FACC, director of heart failure and transplant cardiology at RWJ University Hospital. As soon as word of the Duke incident was made public, and before much information was available about how it happened, Freudenberger called a multidisciplinary meeting to assess the risk of a similar incident occurring at RWJ.
"We had the same response that anyone would have when you witness a terrible car accident," he says. "We were stunned and deeply saddened for those involved at Duke. It’s a reminder that these medical mistakes can occur to anyone. It scares us all when a mistake like this happens."
The meeting at RWJ included the risk manager and anyone who had anything to do with transplant surgeries, from surgeons and nurses to social workers and rehab therapists. Twenty people brainstormed about what they knew of Duke’s incident and how it could be prevented at RWJ.
"Nobody wanted to be the next Duke, of course," says Campbell. "We thought we had a fine system in place already, but I’m sure Duke thought the same thing."
Freudenberger says the group went through the transplant process step by step and identified four points at which the blood-type match is confirmed. The first is when the donor’s local organ-procurement organization checks the blood type; the second is when the national organ-procurement system checks the organ’s type against its database of recipients; the third occurs when the RWJ transplant coordinator is called about the transplant and checks for compatibility; and the fourth is when the transplant surgeon confirms the match before proceeding with surgery.
The system used to stop there, but the RWJ team decided to add a fifth protocol: Two nurses are now required to check blood-type compatibility in the operating room as the surgery begins. This is similar to the standard requirement that nurses confirm the blood type before infusing blood products. The group was enthusiastic about implementing the additional step because the Duke incident scared everyone, Freudenberger. Without that wake-up call, the team probably would have resisted adding another step to the process, he says.
To implement the system, RWJ called a meeting of operating room staff, nurses, and administrators to work out the details of exactly how the fifth protocol would work. They developed a new form for the nurses to use, and the new process was implemented at RWJ only two days after they first heard of the Duke incident.
Campbell says the additional protocol for transplant surgery makes everyone at RWJ more confident that they will prevent such tragic accidents from occurring, but he says risk managers should take away a bigger lesson about the dangers of complacency. You can never assess your systems and processes too much, he says, and you should remember that sometimes a seemingly obvious and basic step — like confirming a blood-type match — can make a difference between life and death for a patient.
Freudenberger agrees, saying the incident drove home for him the importance of having multiple levels of checks and balances, as well as a written protocol that everyone must follow.
"There’s no way to know when you have enough checks and balances, but it’s hard to have too many," he says. "Hopefully, we will never find out we have too few."
Hospitals across the country are taking a hard look at their processes to spot weaknesses similar to those at Duke University Hospital, where a patient died because of a lack of redundancy in the system for matching donated organs.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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