Earlier this year, a woman volunteered to donate a kidney for a man who needed a kidney transplant. On April 6, surgeons at University of Pittsburgh Medical Center (UPMC) removed the woman’s kidney and transplanted it into the man.

However, the transplant surgery should never have happened. On May 2, a follow-up test on the donor came back positive for hepatitis C, a dangerous and potentially deadly virus. According to a recent report, a pre-surgery test also found a hepatitis C infection, but that positive test result was ignored due to hospital negligence and mistakes by multiple physicians involved in the transplant.

The Centers for Medicare and Medicaid Services (CMS) launched an investigation into the incident. CMS found that the donor did not know that she was hepatitis C positive, but she was tested for the virus as part of a pre-transplant review and that test came back positive on January 26, weeks before the surgery.

The donor’s hepatitis C status appeared in her medical record, but everyone connected with the surgery missed that vital piece of information, leading to the donor’s kidney being transplanted into a man who did not have the virus.

After the positive test, there were at least two meetings of hospital staff to discuss the donor’s status. Even though UPMC’s medical record system indicated that the donor had hepatitis C, she received final approval to donate at a March 23 meeting of the hospital’s multidisciplinary selection committee.

According to the CMS report, there were no fewer than six chances to review the test result and stop the transplant. UPMC initially blamed the lead surgeon and demoted him. The hospital also suspended the transplant coordinator involved with the case. However, the CMS report also blames the nephrologist involved in the case, who reviewed the donor’s health status before the surgery.

UPMC shut down its kidney transplant program on May 6, but recently received approval from the United Network for Organ Sharing to resume performing transplants. Presently, it is not publicly known if the man who received the transplant has been infected with the virus.

Source: Pittsburgh Post-Gazette, “Transplant error finds more at fault,” Sean D. Hamill, July 19, 2011