Status:
Rejected
Record number:
1154
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Not reported
Time to detection:
Immediate
Alerting signals, symptoms, evidence of occurrence:
Kidney accidently discarded that had just been removed from a living donor. It had been placed unlabeled in an ice bucket then inadvertently flushed down the OR hopper. Personnel did not see the kidney in the ice. The recipient, having been anesthetized but not incised has been awakened and informed of the events.
Demonstration of imputability or root cause:
Upon further examination, the surgical staff realized that the kidney must be discarded due to the extended warm ischemia time and loss of sterility
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Suggest new keywords:
kidney
discard error
living donor
labelling error
operating room
Suggest references:
add these: http://www.toledoblade.com/attachment/2012/08/22/UTMC-Letter-on-Kidney-Transplant-Program-Suspension.pdf
http://www.toledoblade.com/attachment/2012/09/27/Dr-Levy-s-report-on-his-site-visit-to-UTMC.pdf
Note:
OK ONCE THE REFERENCE IS INDEXED (EVI)
I would suggest posting a primary source of information that is "UTMC review finds nurse failed to follow procedures in botched kidney transplant - Thursday, 09/27/2012 - THE BLADE". In this case, the documents listed are non-public information of the University of Toledo (see note at end of text). So I propose to publish the primary source (in PDF) and documents of the University of Toledo (also in PDF).
http://www.toledoblade.com/Medical/2012/09/27/UTMC-review-of-kidney-program-finds-system-problems.html
SAB: 9-20-2020: the Blade article is no longer available on their website; the investigative letter from HRSA we have as part of our PDF is protected by confidentiality policies (it cannot be used here). I believe this requires discussion by the group regarding whether to: 1) post it in the Library but only use the PDF of the article from the Blade that was publicly available, or 2) reject it and archive this one and not post it in the Library.
Expert comments for publication:
Only reference found was from a newspaper article