Report: Poor communication led to kidney being trashed at UTMC
Tue, 25 Sep 2012 13:01:02 GMT —
A lack of communication is to blame for a botched kidney transplant at the University of Toledo Medical Center, according to a report released Monday.
A 13-page-report, released by the Ohio Department of Health, details how a kidney donated from a living donor in early August was discarded before it could be transplanted into the recipient - the donor's sister.
The report begins by stating UTMC failed for meet acceptable standards in the practice of surgical services. "Based on interview, clinical record review, policy review and observation, the facility failed to ensure adequate supervision and communication was provided in the operating room and failed to have adequate policies in place to achieve a high standard of patient care to prevent the disposal of a viable donor kidney..."
UTMC, the former Medical College of Ohio, has since suspended its live-kidney donor program.
According to the report, "Nurse A" was on a lunch break when the kidney was removed from the donor and placed into a "slush machine" to preserve it for donation. Upon her return to the operating room, and unaware that a kidney had been placed in the machine, that nurse removed the slush machine from the room and disposed of its contents. A second nurse states, in the report, that Nurse A did not ask anyone in the operating room what had occurred while she was on break. Nor did anyone in the operating room inform her of what transpired while she was away - specifically that the kidney had been placed in the slush machine. Nurse A told investigators that normally the donor kidney is placed in the recipient's room; therefore, she believed the machine was not carrying the organ when she discarded its contents.
UTMC has suspended a part-time nurse involved in the incident. That nurse resigned Sept. 10. Another nurse has been fired from the institution. It is unclear as to which role each of these nurses played inside the operating room during the botched surgery.
The transplant was led by Dr. Michael Rees who has since been stripped of his title of surgical director of renal transplantation. He remains on staff as a surgeon at UTMC.