Patient receives kidney meant for someone else, hospital says

[left-of-center2012]

CLEVELAND (AP) — An Ohio hospital has acknowledged that a patient received a new kidney meant for someone else. Officials at University Hospitals in Cleveland on Monday apologized for the mistake and said two employees have been placed on administrative leave. The kidney given to the wrong patient is compatible and the person is expected to recover, officials said.

The other patient’s surgery has been delayed. Officials said the hospital is reviewing how the error occurred to prevent similar mistakes going forward.

“We have offered our sincerest apologies to these patients and their families,” hospital spokesperson George Stamatis said in a statement. “We recognize they entrusted us with their care. The situation is entirely inconsistent with our commitment to helping patients return to health and live life to the fullest.”

The hospital has notified the United Network for Organ Sharing, which manages the national transplant system. A message seeking comment was left Tuesday with hospital officials.

https://www.pennlive.com/nation-world/2021/07/patient-receives-kidney-meant-for-someone-else-hospital-says.html

[hlthe2b]

1. Fortunately error was with a kidney. Had it been a heart or lungs, intended patient would likely

be dead. I doubt any apology could "fix" that.

I seriously don't know how this could have happened by error...

[zuul]

2. Holy shit! I wonder how this happened.

My brother is the chief profusionist at a major midwestern hospital. There are so many protocals in place to prevent this kind of mistake from happening. I bet every transplant unit in every hospital in the US is reviewing their policies.

[Kali]

18. surgeries as production lines

that is how

[Bayard]

3. Article doesn't say whether the recipient actually NEEDED a kidney

What if he was in for a colonoscopy? (yes--I am being facetious).

[lame54]

11. The worst part is...

He still has the wart on his hand that he came in to get removed

[Docreed2003]

4. Something is fishy here

I can only speak to my experience in training but when we had a transplant those patients who are receiving the organ aren't usually in the hospital. So you're calling them in, you're going over their history, you're verifying all of the donor services info. It's not like you just "oops" put the wrong kidney in the wrong patient. Even if you were placing multiple kidneys in the same day, there were numerous safeguards in place.

[unblock]

5. speaking as an engineer, *any* process, is subject to error (some more than others)

there are methods to reduce the error rate, such as redundancies and double-checks and testing and feedback indicators and automation, but still, essentially any process has a non-zero error rate.

in this case, we don't have a lot of information, but it sounds like the actual recipient was simply lower on the priority list, so that patient wouldn't have known anything was amiss. they were waiting their turn and told the wait is over, why would they think anything was wrong.

if the kidney was compatible, there wouldn't have been anything about the match that looked problematic for the hospital staff either.

sounds like the only issue was that the originally intended recipient was somehow marked as off the list for some reason, so the person next in line was matched with the kidney.

single point of failure. the question is how was the higher priority recipient overlooked. the article doesn't say.

[Wounded Bear]

6. The old saying goes: "If you think you've designed a foolproof system...

you're underestimating the creativity and tenacity of fools."



(Yeah, I was an engineer in a former life

[unblock]

7. yeah, this comes up with automation a lot. people just assume it eliminates errors

with proper testing it can indeed virtually eliminate *certain kinds of* errors.

but it also introduces completely new errors, including some that humans would never, ever make.

for instance, a well-tested bit of software is extremely likely to be able to add up a set of numbers in a database accurately. however, if the data itself was off, it may blithely produce an answer that is completely nonsensical because computers don't have "common sense". this is how sometimes you hear a story about someone getting a utility bill for several billion dollars. that's the kind of error only a computer could make.


and any time something gets used a lot, and by a lot of people, eventually someone will do something... unexpected....

[Wounded Bear]

8. I worked mainly in hardware, but similar problems exist...

I used to say anybody can make one thing work, the real problems come up when you try to make a million of them.

Non-tech typed don't understand how tolerances work.

[Docreed2003]

9. That's kinda what I think smells fishy

If a patient was skipped on the transplant list to give another patient priority, that would explain the situation and why there was a "match" for this kidney.

I get that errors can occur at any point, but, knowing what I know personally about how the transplant process works, it just doesn't add up that they "accidentally" transplanted a kidney into a patient who just happens to be a match as well. The match process alone makes that highly unlikely that two people who would be a match for the same organ would be in the same hospital at the same time.

[unblock]

10. they might have been leaning on the rarity of the match to cover a weak priority check

so let's say they have a poor process for matching a kidney with the top priority, and sometimes they pair it to the number two priority recipient. but then they have many good checks to make such it's compatible, and since 999 times out of 1,000 it's not, that check exposes the pairing error and they re-pair the kidney with the proper recipient.

but if that error happens enough, eventually they'll hit that 1 in 1,000 case where it happens to be a match with the other recipient and that's why we're hearing about this case (but not about the other 999).


unfortunately all we can do is speculate. if you're suggesting that maybe someone deliberately screwed with the prioritization -- maybe someone in a position to reassign the kidney was a friend of the family of the lower priority recipient -- yeah, that's also possible.

[lame54]

12. Or fraud...

They may have successfully cut in line

[unblock]

13. certainly possible, though of course a good process should reduce the likelihood of that as well.

just like a process for how a company handles its cash. it needs a process that protects against errors, but also that protects against embezzlement.

there are obviously massive incentives to cut in line when it comes to transplants, so the processes should address those risks.

[lame54]

15. Of course it should - fraud is difficult to pull off...

Could have lied their way through the double check process

What are the odds that the kidney was a perfect accidental match?

[unblock]

17. see post #10. the odds are long, but we don't know out of how many times.

[ZonkerHarris]

14. Why do I feel that the person with the kidney is wealthy? Just my gut feeling...

[Ms. Toad]

16. I have to say, it doesn't surprise me.

While I haven't had any care-related issues (that I know of) arise from it - their computer system is crap.

They are my breast cancer hospital. Whenever you have cancer, you get a team assigned to you. The breast cncer team cannot communicate with each other via my records. My records for a single disease (the only one for which UH is treating me) are stored on two separate computers, which cannot communicate with each other. I can only communicate with half of my care tem via the charting system (and can access only half of my records and appointment information).

When I was diagnosed with sarcoma earlier this year, one of the first communications I made (beyond family) was to my breast cancer team. I figured each cancer care team should know about the other, and about the care each was providing.) The critical physician was unable to access my message - so she learned that I had cancer that might benefit from radiation after the critical 90-day window to start radiation. (She was pissed that I rejected it - she wanted a chance to talk me into it.)

A single visit recently (in whch they copied my insurance card and accepted my copay) resulted in me being reported to a third party entity as uninsured for half of my treatment, but insured for the remainder. (And when that third party entity called me to offer with assistance in paying the bill, the woman on the phone indicated most of the people she is callint are responding the same way.)

My daughter has been able to have emergency care professionals access her complete medical records from out-of-state (different hospital system) - but UH can't even internally communicate completely.

(The care I receved was superb - but communications suck.)