Upon removal from a donor patient, a healthy kidney was placed in a metal basin inside a slush machine. The kidney was intended for the donor’s sister. Before it could be transplanted, the kidney was flushed down the hospital’s medical waste system by a part-time nurse. The medical error drew significant headlines and has caused the hospital to temporarily suspend its live donor transplant program and review its policies and procedures regarding organ transplant surgeries.
Medical mistakes happen every day. While many go unreported, some capture the public’s attention and lead to furious, if generally brief, discussion over how such a thing could occur. The truth is that medical errors cause many thousands of deaths every year and millions more injuries. The President of the medical facility indicated that this error was unheard of, but that lots of other issues are known to be problem areas in transplant surgeries.
In response to the error, the hospital has made several changes. The nurse in question had left for a lunch break during the procedure and was not briefed on its progress when she returned. The hospital has therefore instituted a policy that all members of the surgical team must check with the surgeon before going on break. The hospital has further required that nothing be allowed to leave the operating room until the patient has been removed after the surgery. The containers in which organs are placed after removal have been changed, and now include a label. Devices have been attached to slush machines that will provide visual and auditory alerts when the machines are lifted.
Source: Toledo Blade, “Changes in place after botched surgery,” by Jennifer Feehan, 7 October 2012
