hospital introduces new procedures after human error resulted in failed kidney transplant

Back in August, our blog reported a shocking story of how “human error” at the University of Toledo Medical Center somehow caused a kidney taken from a live donor to be rendered unusable for transplant.

In the immediate aftermath of this devastating mishap, UTMC declined to release information about the incident, including how the kidney was ruined and who was responsible for it. However, over the last few months more details have emerged and they paint a truly unbelievable scene.

In a typical living donor kidney transplant, the kidney is removed from the organ donor, flushed of their blood, packed in ice inside a sterile plastic bag and placed inside another sterile container filled with an icy slush mix. It is then taken to a nearby operating room where it is implanted into the organ recipient.

Surgeons will usually transplant the kidney into the recipient within an hour of removal, even though it can remain viable for up to 48 hours. Experts indicate that the entire procedure usually takes anywhere from two to three hours.

In the UTMC case, it appears as if the kidney taken from the living donor was prepared in accordance with the procedure outlined above, but that the OR nurse somehow forgot that the kidney was inside the icy slush mix and accidentally threw it out.

Once the shocking discovery was made and the kidney retrieved from the medical waste system, surgeons unsuccessfully attempted to revive/resuscitate it for upwards of two to three hours before ultimately deciding to abandon their attempts.

Sadly, sources with firsthand knowledge of the medical mistake indicated that the kidney — a perfect match — was being donated by a brother to his ailing sister.

UTMC has since suspended its living kidney donation program and instituted a new system of procedures in the aftermath of the error that one expert referred to as “baffling.”

Some of these procedures include:

  • No items may leave the OR until the surgery is complete and the patient has been removed
  • Surgical team members must check with the surgeon before leaving for a break
  • The slush machine has been outfitted with an infrared motion detector that creates a noise anytime someone comes within a certain distance
  • The slush machine has also been outfitted with a magnetic top that sounds an alarm whenever it is lifted

If you think that these procedures would serve as a model to the rest of the country to prevent this one-of-a-kind accident from occurring ever again, guess again.

“The fact that this hasn’t happened anywhere else is probably because there are already checks and balances in place,” said one expert.

It should be noted that two UTMC employees involved in the incident are no longer employed by the facility. The part-time nurse who threw out the kidney resigned, while a full-time nurse was terminated. Here, hospital officials claim she stood in for the part-time nurse while she went on a break but failed to properly update her upon her return to the OR.

If a serious surgical error or nursing error at a Pennsylvania medical facility has compromised your long-term prognosis, consider consulting with a legal professional who will work to secure the justice and peace of mind that you deserve.

Sources: The Toledo Blade, “Changes in place after botched surgery,” Jennifer Feehan, Oct. 7, 2012; The Toledo Blade, “UTMC suspends kidney exchange over human error,” Ignazio Messina, Aug. 23, 2012

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