Surgeon, officials review Ohio transplant error

COLUMBUS, Ohio (AP) — Health officials and a consulting surgeon are reviewing a living-donor kidney transplant program that's been temporarily suspended by a northwest Ohio hospital, where a donated kidney apparently was put with medical waste instead of going to the intended recipient in what medical experts describe as a rare accident.

The University of Toledo Medical Center apologized and put two nurses and an administrator of surgical services on paid leave without public explanation following the Aug. 10 error. It also sent letters notifying 975 patients and potential organ donors and recipients that they may need to make other arrangements for services typically provided through the program under review.

UTMC is "committed to ensuring safeguards are put in place to prevent such an incident from ever happening again," Dr. Jeffrey Gold, the vice president for health affairs, said in a statement. The review is expected to take several weeks.

State health officials say they're looking into the error on behalf of the Centers for Medicare and Medicaid Services, and UTMC hired a Texas surgeon to evaluate its transplant procedures. Dr. Marlon Levy, surgical director for transplantation at Baylor All Saints Medical Center at Fort Worth, was expected to visit Toledo on Thursday and Friday.

The hospital has refused to publicly share much detail about how the kidney was rendered unusable during the transplant, which typically is an hourslong surgery involving a five-person medical team removing the organ from a donor, transferring it to a steel container and transplanting it to a patient in close proximity.

"Somehow, some way, an inexplicable human error made someone think that the kidney apparently was already in the recipient body when it was not," the UTMC president, Dr. Lloyd Jacobs, told The Blade in Toledo.

The local health commissioner, Dr. David Grossman, told the newspaper that a doctor who was involved said a nurse accidentally disposed of the kidney. Grossman did not respond to phone messages from The Associated Press.

The man who donated the kidney and the intended recipient, his sister, have been released from the medical center. The hospital hasn't identified the family, and it can't say whether the sister has received a different kidney, UTMC spokesman Tobin Klinger said. There was a "good chance" of finding another compatible donor, the facility has said.

Kidneys are the most commonly transplanted organ. More than 5,700 kidney transplants involving living donors and 11,000 with deceased donors were performed last year in the United States, according to the Organ Procurement and Transplantation Network, which maintains the national patient waiting list and is administered by the United Network for Organ Sharing. UTMC performed 16 of those living-donor kidney transplants and 37 deceased-donor transplants in 2011.

The types of problems that lead to unsuccessful transplants — and occasionally program suspension or termination — are uncommon but can include an unexpected donor disease transmission or the death of a living donor, said Joel Newman, a spokesman for UNOS, the private, nonprofit, government-contracted organization that manages the organ transplant system in the U.S.

"The occurrence of such events is rare, but in those instances it is a very common procedure for the program to inactivate for a period of time, do some root cause analysis and really try to address any sort of issues that can be corrected," Newman said.

As UTMC takes such steps, three workers are suspended. The administrator of surgical services, Edwin Hall, isn't commenting, according to a woman who answered the phone at his Michigan home on Wednesday. The two suspended nurses, Melanie Lemay and Judith Moore, could not be reached for comment.

The surgeon involved in the transplant has not been suspended.

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Follow Kantele Franko on Twitter at http://www.twitter.com/kantele10 .
Associated Press
Copyright 2012 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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