Hospital's kidney program suspended after botched transplant, investigation
November 1, 2012 3 minutes read
Hospital's kidney program suspended after botched transplant, investigation
The accidental disposal of a donor kidney has resulted in a hospital suspending its kidney donor program and a review of the hospital's compliance with regulations. The hospital also is facing bad publicity and the potential for malpractice lawsuits.
A nurse at the University of Toledo Medical Center accidentally disposed of a living donor's kidney during a transplant procedure, according to a report prepared by the Ohio health officials at the request of the Centers for Medicare and Medicaid Services (CMS). The nurse told investigators she did not realize the donor kidney was in chilled, protective slush that she removed from an operating room, took down a hall to a dirty utility room, and "flushed down a hopper," according to the report.
Errors such as this one usually point to a systemic problem within the hospital, explains Karl J. Protil Jr., JD, equity shareholder with the law firm of Shulman Rogers Gandal Pordy Ecker in Potomac, MD. It would be a mistake to dismiss the incident as simply a failing by the individual nurse, he says. "This is like a never event, and those almost always can be traced to a series of events or a series of errors that came together to make this happen," Protil says. "This tells you that something within the hospital needs to be fixed so that this can't happen again." A great proportion of the malpractice cases that Protil handles involve a series of errors or omissions, he says.
The nurse said she had been on a break when a surgeon told everyone the kidney had been put in the sterile, semi-frozen solution. (The full report is available online at http://tinyurl.com/ohiokidneyreport.)
Hospital administrative staff members interviewed by health investigators said they did not know how the nurse was able to take the 13-gallon bag of slush, meant to extend the kidney's viability, past several members of the medical staff without them noticing a problem, the report said. It said poor oversight and communication and insufficient policies were factors in the kidney's disposal, which prompted the voluntary, temporary suspension of the hospital's living-donor kidney transplant program and led to reviews by health officials and a consulting surgeon hired by the hospital. The hospital "failed to provide adequate supervision and communication resulting in a donor's kidney being carried out of the operating room, down a hall, into a dirty utility room, and flushed down a hopper," the report stated.
The hospital has since enacted clearer policies to clarify communication between nurses who fill in for one another and to make sure nothing is removed from an operating room until the patient has been moved from it, the report said.
The surveyors determined the hospital was not in compliance with CMS conditions of participation for transplant and surgical services. CMS issued a statement saying it will conduct a full review of the conditions of participation for the hospital. If found out of compliance, the hospital could be banned from Medicare and Medicaid participation.
Requests for comment were not answered by the hospital, which has not said what happened to the intended kidney recipient, the sister of the donor. The hospital issued a statement confirming that the intended recipient and her brother were released from the hospital.
Hospital officials apologized publicly and hired a Texas surgeon to evaluate their transplant procedures. The medical center suspended two nurses after the incident; one was later fired, and the other resigned, according to the hospital. A surgeon was stripped of his title as director of some surgical services, and a surgical services administrator that was put on paid leave has resumed work.
The hospital also notified 975 patients and potential organ donors and recipients that they might need to make other arrangements for services typically provided through the program under review.
Source
Karl J. Protil Jr., JD, Equity Shareholder, Shulman Rogers Gandal Pordy Ecker, Potomac, MD. Telephone: (301) 230-6571. Email: [email protected].
The accidental disposal of a donor kidney has resulted in a hospital suspending its kidney donor program and a review of the hospital's compliance with regulations.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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