I Hate Dialysis Message Board
Dialysis Discussion => Dialysis: News Articles => Topic started by: Zach on July 08, 2012, 10:04:29 AM
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I suppose you can file this under "not all transplant centers are equal."
8)
Methodist Hospital Puts Kidney in Wrong Patient, Suspends Transplant Program
By Eric Nicholson
Dallas Observer
Published Thu., Jul. 5 2012 at 4:00 PM
http://blogs.dallasobserver.com/unfairpark/2012/07/methodist_hospital_puts_kidney.php
A little while ago, WFAA reported that Methodist Dallas Medical Center had made a teensy error during a recent operation and transplanted a kidney into the wrong patient. The kidney turned out to be compatible and the patient is fine, but when Methodist discovered the mistake last week, it raised red flags and prompted the Oak Cliff hospital to voluntarily suspend its kidney and pancreas donation program.
There aren't a lot of details about exactly what happened -- just that, as a result of "human error, our process of matching the donor identification number to the recipient's name was not followed," according to a statement released by the hospital. The human who made the error, who is not being identified, is no longer with Methodist.
Joel Newman, a spokesman for the United Network for Organ Sharing, which oversees the system that matches organ donors and recipients under a federal contract, said inadvertent transplants are "rare but not unheard of." He didn't have any statistics but said that in 20 years with the organization, he's encountered "a handful."
Newman said he couldn't talk specifics about the Methodist case but, in general, the agency convenes a peer review committee to investigate transplant mistakes. If the committee finds serious or systemic problems with transplant procedures, it issues a public determination that the institution is on probation or not in good standing. That rarely happens. In the vast majority of cases, UNOS works with hospitals to bring their programs back into compliance.
I've asked Methodist for additional details, such as when the transplant took place, how it was discovered, and when they hope to relaunch the transplant program. Meanwhile, the 208 patients actively awaiting transplants can have them done at another hospital if an organ becomes available.
Update at 5:17 p.m.: Methodist sends along some additional information.
During 2011 Methodist provided 58 kidney program transplants including 47 single kidney, 2 kidney/pancreas, and 9 kidney/liver transplants. Additionally, there were 44 liver-only transplants in that program.
We have notified both the patients awaiting transplant as well as all previous transplant patients. We took immediate action to begin an internal review to ascertain the root cause and put additional protocols in place to ensure the continued safety of our patients. For 31 years, the Methodist Dallas Medical Center Transplant Program has provided the highest quality of care, safety and service for our donors and recipients as evidenced by our consistently superior patient and graft survival results. Our foremost commitment is to our patients and their safety and we will work diligently to resume the life-saving work in caring for our kidney and kidney/pancreas transplant patients very soon.
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If the kidney went to the wrong person, I feel especially sorry for the person who was supposed to get it!
Good to see you posting, Zach.
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At the very least some one who needed a kidney, got one and it was compatible. Otherwise, BOO!!
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Same thing happened here in Los Angeles. UNOS doesn't provide barcodes or tracking for organs so whoever is on the receiving end has to manually check numbers and schedule the surgery. The hospital here skipped that step and went straight to crossmatching, which was fine for first recipient. But when the next kidney arrived it didn't match the 2nd patient, and thats when the error was discovered.