A recent post on the Living Kidney Donors Network Facebook page contains a link to a Aug 2012 story in the Toledo Blade about an operating room error that led to the irreversible loss of a live donor kidney.

LKDNFacebookPost

The accident occurred at the University of Toledo Medical Center on August 10. The donor was a man whose intended recipient was his older sister. It appears that the surgery to remove the kidney from the donor was successful. But through some error, the kidney was not properly handled and ended up with the medical waste. The surgeons spent two hours trying to recover it, but ultimately decided not to proceed with the transplant.

This is a tragic event. The emotional trauma being felt by both the patient and the donor is hard to imagine. If you are a potential kidney donor and feel that you may drop out due to this shocking story, I have a few comments that I hope will give you the reassurance to stay in the transplant program at whatever hospital you are at.

First, this is a very rare event, as it should be. There have been about 4,000 live donor transplants conducted so far this year in the U.S. and about 50,000 total in the past decade. I’m not aware of any similar story involving the a live donor kidney rendered medically unusable after removal. (It is common for deceased donor kidneys to not be usable and eventually discarded, but the conditions are quite different.)

Second, there will be an investigation into the cause of this error and recommendations on how to prevent it from happening again. This information will be shared with all transplant centers in the U.S. to improve safety nationwide.

The UTMC transplant program has been voluntarily suspended during the investigation. An outside investigator, Dr. Marlon Levy, the surgical director of the transplant program at Baylor All Saints Medical Center in Fort Worth, will be brought in to review the program. The review will also include officials  from the Organ Procurement and Transplantation Network (OPTN), a nonprofit organization that monitors all transplant programs in the U.S.

In a June 2010 blog post, I mention that most accidents, not limited to the medical field, are caused by system failures not simply an individual mistake. For instance, perhaps a safety checklist or communications checklist wasn’t in place or wasn’t used properly to prevent this error. Unfortunately, the Toledo Blade article names the individual nurses who have been placed on administrative leave, implying they are solely to blame. Reading the comments on the story as well as on the LKDN Facebook page indicates most readers also place blame on the nurses. However, I believe much of the blame should be placed on the administrators, surgeons, and training staff who failed to implement and maintain the safety program.

Finally, the accident at UTMC has immediate impact on a lot of patients now. While the UTMC program is suspended, any kidney patient awaiting a transplant at UTMC will be delayed. Some of these patients may be able to transfer to another hospital (there are nine transplant centers in Ohio), but most will have to wait until the UTMC reopens.

Also, one of the surgeons involved in this accident is Dr. Michael Rees, the founder of the Alliance for Paired Donation, a kidney exchange program frequently mentioned in this blog (for instance, see Nov 2009). Since many of the kidney exchange operations involve UTMC, the temporary suspension of the UTMC program could delay transplants for a lot of patients around the country. Thus, although suspending the UTMC program is an important step to increasing safety, keeping it closed for an extending time would be bad and may lead to patients on the transplant waiting list dying.

In closing, I urge any potential donors who may be having second thoughts about undergoing surgery to not back out now and to remain committed to giving the gift of life.

[Update: The investigation is complete and a report issued. An Oct 2012 blog post describes the findings and changes to be made to the program.]

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