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CLEVELAND (WJW) – University hospitals change their policies after a transplant patient receives a kidney for another patient.
The kidney was compatible, but the failure delayed the transplant for the other patient. Two nurses were given leave of absence.
“The incident resulted from a protocol disruption during the organ verification process,” said Cliff Megerian, chief executive officer of the university hospital, in a message to staff on Friday.
“We are aware of the pain this situation has caused our patients, their families and also our carers. The mistake should never have happened and it runs counter to the goals of safety and excellence that we advocate across our healthcare system. Fortunately, the patient was discharged from our hospital and is recovering well so far. “
The university hospitals announced that they immediately notified the United Network for Organ Sharing and are working with the Ohio Department of Health.
In Friday’s memo, Megerian also announced the following actions:
- Establishment of a Zero Harm Executive Cabinet.
- Review of our transplant policies and procedures, which have been changed to increase redundancy in examining organs and patients.
- Conducting training with appropriate transplant personnel to strengthen compliance with organ verification protocols.
- Initiate a project to determine the feasibility of including barcode validation in organ verification.
- Extended evaluation of the incident to include a more comprehensive assessment of our transplant program.
- Start engaging an expert third party to conduct a cultural safety assessment of the transplant program.
