The University of Southern California (USC) claims they have corrected what they term a flaw in the system that allowed a group of surgeons to transplant a kidney into the wrong patient last January. The wrong transplant occurred when the wrong organ ID wound up on the wrong paperwork. Once that mistakewas made, surgeons were essentially given the okay to proceed with the transplant.
One of the things that a rep has learned is that this ‘rare’ occurrence is not unique to USC. There are similar procedures in use at other transplant centers across the country. The ‘rare’ event started as two kidneys arrived at USC for transplant on the same day. The USC University Hospital performs two transplants a week at the most. Another contributing factor to this rarity is that both kidneys were for the left side, and both kidneys were for someone with type O blood.
Normally, the nurse is to record the operating room booking slip, which includes the organ donor ID number. On this occasion, no number had been recorded. At this point, the nurse is supposed to transfer the number from the operating room booking slip to a blood verification form. This was to serve as a final verification that the blood types and correct organ are matched. Sources have said that since there was no organ donor ID number on the booking slip, the nurse got the number from the box that contained the kidney. The problem is that was the wrong kidney.
The final check and balance that occurs at that point of the process also failed. It failed since the nurse had gotten the wrong number from the wrong location. This meant that the doctors and nurses all verified the wrong number. The operation proceeded.
Fortunately, the patient that received the transplant that day survives and is reportedly doing well. Everyone concerned is fortunate that the organs were of the same blood type. The person that was scheduled to have received that kidney is still on USC’s waiting list, however.
Although state and federal authorities continue to investigate what went wrong, this same system flaw had gone unnoticed by many for a very long time. It had even gone unnoticed from the same state and federal investigators that are now investigating the incident. In the meantime, USC has made their necessary improvements to their system in order to ensure that this does not happen again, and will resume their transplant schedule. So
have hospitals in Nassau and Suffolk Counties.
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