UPMC disciplines 2 members of kidney transplant team

[okarol]

UPMC disciplines 2 members of kidney transplant team

Thursday, May 26, 2011

By Jonathan D. Silver, Pittsburgh Post-Gazette

UPMC today confirmed it has disciplined a surgeon and a nurse involved in a kidney transplant earlier this month in which a positive test result for hepatitis C in the live donor that might have stopped the surgery was missed by the medical team until it was too late.

In addition, the hospital system said it has voluntarily suspended its prestigious live-donor liver program as a precaution. UPMC temporarily shut down its live-donor kidney program following the hepatitis C snafu.

That program remains closed.

UPMC spokeswoman Jennifer Yates today refused to divulge any details about the identity of the surgeon or nurse. She would not characterize the demotion or release specifics of the suspension. It is not clear whether the surgeon and nurse were part of the team operating on the kidney donor or the recipient.

"It's a personnel issue, and I really can't say anything more than that," Ms. Yates said this morning.

On May 6, UPMC informed federal authorities about the hepatitis C problem, prompting county, state and federal investigations, as well as a review by the United Network for Organ Sharing.

Ms. Yates could not say when the live-donor liver program was halted, but said it was a temporary situation.

"We also voluntarily suspended the live-donor liver program as a precautionary measure. There have been no issues with that program," she said.

Ms. Yates did not have information on what prompted UPMC to take that step.

However, on May 11, two days after news that a kidney had been transplanted from an infected donor, Elizabeth Concordia, UPMC's executive vice president, briefed board members of the hospital system on the situation.

She told them, according to one board member, that the positive test result for hepatitis C was missed by two people on the transplant team during a dozen steps in the process. She called that a "systemic" problem in the way the protocols failed in that one case, the board member said.

Ms. Yates said there is no date established for restarting its live-donor transplants. The kidney program is on hold at least until the UNOS review is complete.

"Once we hear something from them we'll make a decision," Ms. Yates said.

Jonathan D. Silver: jsilver@post-gazette.com or 412-263-1962.


Read more: http://www.post-gazette.com/pg/11146/1149362-100.stm#ixzz1Nhyxia9b

[Marina]

WOW!!!
scary  if you  ask me!

[Chris]

Since we do not know the full story, my comment could be wrong. It seems these two people are made the escape goats even though they should have caught it prior to transplant, but it was a systemic problem from the begining and what about the donor? The donor if they did not know should be notified, but probably has, but wouldn't someone have told them even before this process began by their own doctor....mind boggling it is.

[Jie]

That is another reason that every patient and donor should get a copy of the lab results and check on them.  Sometimes, professionals make mistakes.

[Rerun]

Isn't the donor usually "dead"?  So, sending the test results back to the donor so they know they have HepC really would be a moot point.

Right?

[sparklelady]

I believe it was a live donor.

[M3Riddler]

Isn't the donor usually "dead"?  So, sending the test results back to the donor so they know they have HepC really would be a moot point.

Right?

Yes,

it was a live doner.  the problem wasnt that the tests didnt show that Hep C was present, but rather 2 people failed to notice the results and the transplant was carried on.  It should have been picked up.  They do many tests that includes more than just a blood test. but they test tissue of the organ and also many other methods....   
There are many patients that do not know they have this disease that are walking about with it.

[lawphi]

My center forwards all lab results to me after review. The nephrologist made a notation beside the hep c/hiv and wrote a quarter size ok and his initials.