USC shuts down kidney transplant program after mistake

USC to resume kidney transplants in wake of mix-up
The head of the USC transplant program says a flaw in the system, which allowed a kidney transplant for the wrong patient in January, has been corrected.

By Lisa Girion and Alan Zarembo, Los Angeles Times
April 6, 2011
Surgeons at USC University Hospital accidentally transplanted a kidney into the wrong patient earlier this year because the system used to verify organs was flawed, the head of the transplant program said Tuesday.

Once the wrong organ identification number ended up on a key piece of paperwork in the operating room, there was nothing to prevent surgeons from proceeding with the transplant, said Dr. Cynthia Herrington, medical director of the USC Transplant Institute.

Her comments came as the hospital announced that it was restarting kidney transplants with new safeguards in place, more than two months after closing the program to investigate the Jan. 29 mix-up.

Herrington said the patient who was supposed to get the kidney is still on the USC waiting list, contrary to an initial report from a local transplant official who said the patient had received another organ.

Transplant experts said the error was highly unusual but that USC was not the only hospital vulnerable to such a mix-up.

"Most transplant centers use similar procedures," said Dr. John Roberts, chief of transplant surgery at UC San Francisco. "This is going to lead transplant centers to reassess how they do things."

A rare set of circumstances lined up to expose what Herrington described as a hole in the system.

First, two kidneys had become available for two USC patients that day. That was a relatively rare occurrence for a program that performs an average of two transplants a week.

Both organs were left kidneys and blood type O.

The error was set in motion when an operating room was reserved for the first patient.

The operating room booking slip — usually prepared by nurses — includes a place to identify the organ by a donor ID number provided by the national transplant system. Nurses then transfer that number to a document known as the "blood verification form," which is used as a final check to ensure that the blood types of the donor and recipient are compatible and that the correct organ is present.

But on Jan. 29, nobody wrote the ID number on the booking slip, Herrington said. When it came time to fill out the blood form, nurses got the ID number from the ice-filled cardboard box that held the kidney, she said.

Unfortunately, it was the wrong kidney.

Now the mistake was locked in place. In the final check, a procedure known as a "time-out" — in which a surgeon and a nurse pause to go over key details — everything appeared to match.

The error was only caught after the operation was completed, the next patient was being readied for surgery and the staff realized that the organ intended for that patient was gone.

"Sometimes you don't know the hole is there until you fall in it," Herrington said.

The transplant program was not blaming individuals but the system itself, she said. Clear instructions were never provided about where nurses should retrieve the ID number for the blood form, she said.

Herrington said she reviewed the procedures when she took over more than a year ago and failed to identify the potential pitfall. The program had been routinely reviewed by federal government and private transplant authorities who never raised the issue, she said.

Dr. Gabriel Danovitch, a kidney specialist at UCLA, said the mistake fits the profile of many dumbfounding medical errors.

"They do not belong to one person but are often a reflection of systemic errors," he said.

The mix-up prompted investigations by state and federal health regulators, which are ongoing.

Herrington said the incident has led to changes in how organs are tracked. Now, as soon as an organ becomes available — and even before it gets to USC — a nurse will be responsible for retrieving the ID number from the national organ network and placing it — three separate times — into the record of the intended recipient.

An electronic medical record system then generates the operating-room booking slip. The new policy also requires the transplant surgeon to print a copy of the donor ID number from the national network and take it to the operating room.

"We own the mistake," Herrington said. "But we put together an ironclad correction plan, and I really feel this will never happen again."

The effect of the error at USC was softened because the kidney that was given to the wrong patient was compatible with her immune system. She is doing well, Herrington said.

She said the hospital didn't lose any patients as a result of the incident. The hospital had 504 patients on a waiting list as of April 1, including the patient whose kidney had been misallocated.

Nationwide, more than 88,000 people are waiting for kidneys, and fewer than 17,000 received transplants last year.

Dr. Ben Vernon, a transplant surgeon at Porter Adventist Hospital in Denver, said no policy is failsafe. He described a recent mix-up at his hospital involving two patients with the same name and blood type.

When a kidney became available, the hospital accidentally called in the wrong patient. But by the time the error was caught, it was too late to call in the right patient, who lived several hours away.

The hospital went ahead with the transplant so the organ would not not be wasted.