UTMC suspends kidney transplant program

[okarol]

UTMC suspends kidney transplant program
BY IGNAZIO MESSINA
BLADE STAFF WRITER

The University of Toledo Medical Center has suspended its living kidney transplant program following a surgery which ended in a usable being kidney ruined.

Dr. Michael Rees, a transplant surgeon at UT who performed the surgery, was not in his office today and could not be reached for comment.

Earlier this month, Dr. Rees said UT, in partnership with his Maumee-based Alliance for Paired Donation, had landed a four-year, $2 million federal grant.

Dr. Jeffrey Gold, chancellor and vice president for biosciences and health affairs at UTMC, the former Medical College of Ohio Hospital, said a kidney removed from a living donor was "rendered unusable" before being implanted into a waiting recipient. The recipient was under anesthesia in an adjoining or nearby operating room but the transplant surgery had begun.

Dr. Gold refused to say how the kidney was ruined and he refused to identify the relationship between donor and recipient.  Two operating room nurses were suspended with pay after the surgery.

According to its Web site, the kidney transplant program has operated for nearly 40 years.

“Since the first kidney transplant operation was performed at The University of Toledo Medical Center in 1972, more than 1,700 kidney transplant operations have been performed, with an average patient survival rate of 98 percent and a graft survival rate of 94 percent,” the Web site states.

A letter written Monday and signed “the Department of Renal Transplant” implied something had gone awry with a transplant.

“At the University of Toledo Medical Center we are committed in our mission to improve the human condition by providing quality, patient-centered health care,” the letter said. “Recently, a process to achieve this failed, so the kidney transplant program decided to voluntarily suspend providing living kidney donor transplant services on August 10th, 2012. Please note that our deceased donor transplant program and all related services are fully operational and are actively managing our patients and families.”

The letter said the hospital could still evaluate potential candidates and living donors and provide transplant recipient follow-up care.

http://www.toledoblade.com/Medical/2012/08/22/UTMC-suspends-kidney-transplant-program.html

[AnnieB]

Wow 

[Fatkidney]

That's scary!

[okarol]

Here's the hospital's announcement, below. I have heard that the Alliance for Paired Donation is also on hold due to this loss of a living donor kidney.---

TRANSPLANT OFFICE
UT-University Medical Center
Dowling Hall
Second Floor, Room 2314
3065 Arlington Avenue
Toledo, Ohio 43614-5807
Fax: 419-383-5728
August 20, 2012
At the University of Toledo Medical Center we are committed in our mission to
improve the human condition by providing quality, patient-centered health care.
Recently, a process to achieve this failed, so the kidney transplant program decided to
voluntarily suspend providing living kidney donor transplant services on August 10th, 2012.
Please note that our deceased donor transplant program and all related services
are fully operational and are actively managing our patients and families. This
suspension of living donor transplant surgery enables us to evaluate and modify our
transplant related procedures and protocols, so we can continue meeting the
expectation of excellent patient service and care.
This voluntary suspension means that The University of Toledo Medical Center is
unable to perform live donor kidney recovery and kidney transplantation surgical
services from live donors during this period.  We can still evaluate potential
candidates and living donors, as well as provide transplant recipient follow up care
during this period. You do have the option of transferring your care to an alternative
facility if this is your desire. We expect the review process to take several weeks, and
we will notify you immediately once our review process is completed.   
So, if you need assistance in determining the impact of this suspension on your
potential for receiving or donating a kidney, please contact your transplant
coordinator using the provided list or call Jennifer Mikulak at (419) 383-4174. Our
transplant coordinators and staff will explain your available options and help you in
any manner necessary.
Attached is information from the United Network for Organ Sharing (UNOS)
describing the services and information offered to patients by UNOS and the Organ
Procurement and Transplantation Network. 
We apologize for the inconvenience and look forward to managing your care.
Everyone’s goal is to ensure that you receive a safe and successful kidney transplant.
Sincerely,
Department of Renal Transplant
University of Toledo Medical Center

[Chris]

Now curious on how did they screw up the kidney to where it could not be transplanted.

[Rerun]

Probably dropped it on the floor! 

       

[Chris]

Probably dropped it on the floor! 

       

That was my first thought and must have been more than the 5 second rule.

[Lillupie]

Probably dropped it on the floor! 

       

i THNK YOU HIT THE NAIL ON THE HEAD THERE!

[AnnieB]

Probably dropped it on the floor! 

       

That was my first thought and must have been more than the 5 second rule.

 

[Chris]

Orrr, orrrrr just an odd thought here since 2 nurses were suspended with pay, the first nurse dropped it and the second one stepped on it by turning around.

[Lillupie]

The newest article is that the kidney actually landed in the trash! I cant believe that! That is crazy! Wow. It was a perfect matched kidney from a brother to a sister.

Lisa

[Chris]

How the heck does it get into the trash?

[Rerun]

They were probably throwing away the old kidney and got mixed up. 

I've done that with old and new cooked hamburger in the fridge before.  Grabbed the wrong one.  Trash.... 

       

I also had a buy one get one free Arby's sandwich and the free one got thrown away but I went after it.   

[okarol]

There was no old kidney. The brother's kidney was removed, and it was supposed to go across the hall to another OR to be implanted in his sister.

[okarol]

Published: 8/28/2012 - Updated: 5 hours ago

3rd suspended in kidney error
Role UTMC official played in transplant not disclosed
BY IGNAZIO MESSINA
BLADE STAFF WRITER
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A third University of Toledo Medical Center employee has been suspended with pay for his involvement in a surgery this month that went awry when a viable kidney was thrown away into a pool of other medical waste instead of being transplanted into the donor's sister.

Edwin Hall, administrator of surgical services, was notified Monday that he would be on "paid administrative leave" from his $164,999-a-year job. Hospital officials declined to elaborate on what role he played in the Aug. 10 surgery.

Mr. Hall of Troy, Mich., could not be reached for comment.

Neither the woman needing the kidney nor her brother, who had intended to donate his kidney, has been identified by the hospital. Tobin Klinger, UTMC spokesman, said the family has asked for "extreme privacy" and the hospital will respect that request.

Two nurses involved in the surgery, Melanie Lemay, a full-time nurse, and Judith Moore, a part-time nurse, have been suspended with pay pending the results of a multi-agency investigation. Dr. Michael Rees, the UTMC transplant surgeon who removed the kidney before it was ruined, has not faced any discipline, said Dr. Lloyd Jacobs, UTMC president.

The hospital has also refused to say which nurse handled the kidney before it was discarded or why a second nurse was suspended.

The UTMC live kidney donation program was voluntarily suspended after the incident.

Dr. Jacobs said he had no doubt the program would be restarted after reviews by the Ohio Department of Health, the Centers for Medicare and Medicaid Services, and the United Network for Organ Sharing, an agency that oversees the nation's transplant programs.

UTMC also is paying Dr. Marlon Levy, surgical director, transplantation, at Baylor All Saints Medical Center at Fort Worth, $2,500 to "review the policies, procedures, and practices of UTMC's living related donor program" and also review management of patients undergoing living related transplants. According to his contract with the medical center, the former Medical College of Ohio Hospital, Dr. Levy is to write a detailed report of his findings, conclusions, and recommendations.

Baylor All Saints Medical Center at Fort Worth has liver, kidney, pancreas, and islet cell transplant programs.

Last week, Dr. Jacobs publicly apologized for the mistake. He said the program would eventually be reinstated after a deep look at the accident. "I share the sentiment expressed by others that this causes great anguish," Dr. Jacobs told The Blade. "I am deeply apologetic. I am anguished. When mistakes are made, the best thing is to acknowledge them and say I am deeply sorry about this."

The kidney transplant program at UTMC has operated for 40 years. It is the only organ transplant routinely performed at the hospital.

Kidneys are the most commonly transplanted organs. There were 16,816 kidney transplants in the United States in 2011 from live donors and from people who consented to organ donation through state registries should they die from an illness or accident.

Dr. Randall Sung, an associate professor in the section of transplantation surgery at the University of Michigan, who is not involved in the UTMC investigation, last week said the two surgeries -- to harvest a kidney, then to transplant it -- typically take two to three hours each.

After removal, a kidney is flushed of the donor's blood and is packed in ice in a sterile plastic bag, which is placed in another container before being moved to the nearby or adjacent operating room with the waiting recipient, Dr. Sung said. He said surgeons usually want to implant a kidney within an hour of removing it.

UTMC has declined to say how long it took to recover the discarded kidney. Once it was found, "efforts were made to restore the kidney to a usable state, however the physician, in consultation with the family, decided to not take the risk knowing there was a good chance for another highly compatible donor," said Dr. Jeffrey Gold, chancellor and vice president for biosciences and health affairs at UTMC.

Doctors tried unsuccessfully for at least two hours to "resuscitate" the organ to make it usable, he said.

Contact Ignazio Messina at: imessina@theblade.com or 419-724-6171.

http://www.toledoblade.com/Medical/2012/08/28/Third-person-suspended-over-failed-kidney-transplant-at-UTMC.html

[Fatkidney]

It seems nuts that this could happen!  The people in that room must not have been paying attention at all. 

[Rain]

wow.  What saddens me is that now that the program is suspended how many people where waiting for a living donor transplant won't get the change until they complete the  review which could take months or years.

[AnnieB]

Published: 8/28/2012 - Updated: 5 hours ago

Doctors tried unsuccessfully for at least two hours to "resuscitate" the organ to make it usable, he said.

Are you telling me they did CPR on a kidney? 

[Lillupie]

Published: 8/28/2012 - Updated: 5 hours ago

Doctors tried unsuccessfully for at least two hours to "resuscitate" the organ to make it usable, he said.

Are you telling me they did CPR on a kidney? 

  CPR on a kidney. lol Good one. True. What did they do?
lol

Lisa

[Rerun]

I'm surprised they didn't just put it in her anyway and then just say "they didn't know why it didn't work .... that just happens sometimes". 

                     :shy;j

At least someone told the truth and didn't go through with the transplant.

[Leanne]

  Rerun.....OMG that is exactly what I was thinking.  I figure that too many people know what really happened though so they had to come clean about it.  I don't think they would have told the truth if they could have covered it up because the lawsuit is just obvious.  And we all KNOW that hospitals and such try to avoid lawsuits at all costs and love keeping things in the house so to speak so that people don't ever hear about the mistakes...

[Chris]

Still a lawsuit is needed since the hospital will still try to charge the two even though they messed up. The donor deserves something out of it.

[okarol]

I'm surprised they didn't just put it in her anyway and then just say "they didn't know why it didn't work .... that just happens sometimes". 

                     :shy;j

At least someone told the truth and didn't go through with the transplant.

Probably were busted when they were dumpster diving