University Hospitals in Cleveland is strengthening its organ transplant procedures after a patient received a kidney meant for another patient, Cleveland.com reports.
In a July 23 letter to employees, Cliff Megerian, the health system's CEO, said the error occurred due to "a breakdown in following protocol during the organ verification process."
"We recognize the pain this situation has caused our patients, their families and also our caregivers. The error should have never happened, and it runs counter to the goals for safety and excellence we advocate throughout our health system," the letter said.
The CEO said transplant policies and procedures have been modified to "increase redundancy in the verification of organs and patients." Other actions the health system is taking include:
- Establishing a zero harm executive cabinet
- Conducting training with appropriate transplant personnel that reinforces compliance with organ verification protocols
- Determining the feasibility of incorporating bar code validation in organ verification
- Expanding evaluation of the incident to include a broader assessment of the system's transplant program
- Engaging a third-party expert to conduct a cultural safety assessment of the transplant program.
The transplant mix-up occurred July 2, and two caregivers have been placed on administrative leave. The kidney was compatible with the patient who inadvertently received it. Transplant surgery for the patient for whom the organ was intended for has been delayed.
"The way we will prevent mistakes is attentiveness to detail and dedication to a culture that puts safety first," Mr. Megerian said in the letter, according to Cleveland.com. "The lessons we learn from this event will be shared systemwide and with other health systems to improve safety everywhere."