University Hospitals Announces Changes After Kidney Transplant Error

University Hospital officials announced Friday they are expanding evaluation of the incident after a person received a kidney meant for someone else on July 2.

UH officials sent a note to employees and the news media Friday which said the incident resulted from a breakdown in following protocol during the organ verification process.

Two UH caregivers were placed on administrative leave after the medical error, according to hospital officials, but the letter to employees provided no additional details about what happened that led to the kidney transplant mix-up or about the fate of the employees involved. 

Hospital officials have not taken questions from the news media about the incident and said in the statement they would provide no further information.

According to the statement UH has reviewed transplant policies and modified them to verify details more frequently to reduce errors.

They have also conducted training with transplant employees about organ verification protocols, hired a third party to conduct a safety assessment of the transplant program, and expanded evaluation of the incident.

UH officials previously said the patient who received the incorrect kidney is recovering, and the kidney was compatible. The surgery occurred on July 2, UH spokesman George Stamatis said in the statement. The other patient’s transplant surgery has been delayed.  

The hospital system, however, has not released updated information about the two patients in several weeks.

UH reported the error to the United Network for Organ Sharing (UNOS), which manages the national organ transplant system.  

According to the announcement released Friday, the hospital has:

• Established a Zero Harm executive cabinet.
• Reviewed our transplant policies and procedures, which have been modified to increase redundancy in the verification of organs and patients.
• Conducted training with appropriate transplant personnel that reinforces compliance with organ verification protocols.
• Initiated a project to determine the feasibility of incorporating bar code validation in organ verification.
• Expanded evaluation of the incident to include a broader assessment of our transplant program.
• Commenced the engagement of an expert third party to conduct a cultural safety assessment of the transplant program.

The hospital released this announcement to their employees. [University Hospitals]