[This is a follow-up to an Aug 28 blog post.]

The Toledo Blade (Oct 2012) has an excellent article summarizing the results of an investigation into an accident that occurred during surgery to recover a kidney from a live donor. The kidney was accidentally discarded and the transplant had to be cancelled. Neither the donor nor the recipient were harmed, but the very valuable kidney was lost. The patient may need to wait, possibly for several years, for a deceased donor kidney to become available.

The accident occurred at the University of Toledo Medical Center, one of about 268 hospitals authorized to perform kidney transplants in the U.S. The report available online, was produced by Dr. Marlon Levy, the surgical director of transplantation at Baylor All Saints Medical Center in Fort Worth. The report summarizes the chain of events that led to the accident as follows.

First, while the donor surgery was in progress one of the circulating nurses took a break. When she returned, she was not briefed on the status of the surgery. She thought the surgery was completed and began the clean up procedure, which includes disposing of the waste ice from a refrigeration unit used to temporarily hold the donor kidney. Unfortunately, the live donor kidney was still in the ice, but was not visible to her. She dumped the ice, and thus the kidney, into the biological waste chute. Although the error was discovered quickly, it took over two hours to recover the kidney. After such a long period of without refrigeration in an unsterile environment, the surgeon decided the kidney could not be safely transplanted into the patient and it was discarded.

This is the first known accident to ever occur in the U.S. in which a medically viable live donor kidney was discarded. As mentioned in the Aug 28 blog post, there have been over 50,000 live donor transplants performed in the U.S. in the past decade without a recorded loss of a kidney. Still, this is a serious error and resulted in the following changes at the UTMC. Hopefully, similar reviews and changes will be implemented in all transplant centers.

Improve communications

● Members of the surgical team must check with the surgeon before going on break.

● Strict adherence to an existing policy that requires a “handoff” briefing whenever a new person enters the operating room. In this case, it was not done, possibly because the new person was not really new, but returning to the operating room from a break and also because she was not a replacement for a person who was leaving.

Set timing of clean up

● Nothing may leave the operating room until the patient has been removed after surgery.

Make the donor kidney easier to view and track

● Use a container with a sealed top to store donor kidney before transplant (see photo below)

● Add a bright label to the refrigeration unit when it contains a kidney (see photo below)

● Add an infrared motion detector to the refrigeration unit that activates an alarm when anyone gets close to it.

● Add a switch to the door of the refrigeration unit that activates a visual and auditory alarm when it is lifted.

These last two changes seem like overkill. Given the seriousness of the accident, it is likely any person who works in operating room will be aware of the risk of losing an organ and unlikely to repeat this error. In fact, focusing so much attention on the refrigeration unit may inadvertently lead personnel to pay less attention to other equipment or procedures that may also have a high risk of causing errors.

UTMC-kidney-transplant-tour-lid

UTMC-kidney-transplant-tour-container-cover

(left) Prototype of new container to be used to store donor kidneys. (right) Plastic tray that will indicate a kidney is in the refrigeration unit. Both photos from Toledo Blade, Dave Zapotosky.

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