According to a report by ABC News, Virtua Health, one of the largest healthcare providers in New Jersey, claimed to have a forty-year history of organ transplant completions.
Nonetheless, a hospital owned by Virtua Health was responsible for transplanting a kidney into the wrong patient with the same name and similar age as the intended patient. It must be noted however that the recipient of the kidney was farther down on the waiting list than the intended recipient. Vitua Health did not discover the error until the day after the operation.
It Could Have Been Worse
Fortunately, and to everyone’s relief, the kidney was an approximate match for the fifty-one-year-old recipient. If it were not a close match the consequences would have been severe.
Another stroke of luck came about a week later when the original recipient received a matched kidney transplant. The names of the two patients have been kept confidential. As of this writing, reports state that both patients are in stable condition.
Virtua Reports the Error
Virtua readily reported the unintentional error. Two officials of the company also visited the patient in the hospital giving details of how and why the error occurred.
The company immediately added preventative measures to its protocol. Educational reinforcement and training were put in place to make every effort to avoid these errors in the future. Virtua’s affiliate is the only hospital in the south New Jersey area capable of providing liver, kidney and pancreas transplants.
A total of thirty million people are diagnosed with chronic kidney disease. There are approximately ninety-five thousand people on the kidney transplant waiting list. The approximate wait time is five years.
An Earlier Transplant Error
In February 2011 the Associated Press reported that the USC University Hospital shut down its kidney transplant program after a patient received the wrong kidney.
The patient was unharmed because in this case the transplanted kidney had blood type ‘O”, close enough for a match.
The hospital spokesman explained that the error occurred when two kidneys were shipped to the transplant center from two separate donors on the same date and at the same time.
Determining a Good Match
To determine if a donor kidney is a good match, doctors will look for an immune response by performing a test involving a mix of cells from a donor with the recipient’s antibodies.
If there is no response, then it is a good match. Conversely, a response is an indication that it is not a match. Moving forward with a transplant in this case could kill either the organ, the patient, or both.
After attending an evaluation by the transplant team, the patient may be cleared to go forward with the transplant. If so, the patient is put on the national waiting list.
Why and How These Mistakes May Occur
A physician at Scripps Research Institute offered an explanation for these very serious mishaps. He said that the large number of medical staff involved with a transplant makes it challenging to coordinate and difficult to communicate.
Multiple organs will arrive at the hospital at odd hours at the same time and for multiple patients. There is also an urgency as the transplant must be performed immediately.
Yet with all the safeguards put in place by the hospitals, it is apparently still possible to call in the wrong patient from the wrong list from the wrong blood group.
As explained by the Scripps’ physician, it is ultimately the surgeon who has the final say about whether the patient on the operating table is the correct recipient.
About Procurement Organizations
Organ procurement is coordinated through specific organizations that connect with patients’ families to recover the organs.
Then, after a match is identified and confirmed, they are responsible for delivery of the donor organ to the patient’s hospital. These organizations also raise awareness about organ donations.