Adverse Occurrence type:
Alerting signals, symptoms, evidence of occurrence:
20 bone and tendon allografts, both corneas and the whole heart (for HV) were recovered by a tissue bank and an eye bank. The physical exam, blood tests, and recovery cultures were acceptable. An autopsy had been performed prior to tissue recovery. Tissue was recovered and some had been distributed when, months later, the final autopsy report was received. It and the entire donor record was examined for final review by the tissue bank QA staff and by the medical director. They discovered a discrepancy between tattoo locations documented on the tissue recovery team physical exam record and the final autopsy report. An investigation showed that tissues had been recovered from the wrong body. The body identification band of an approved prospective donor had incorrectly been placed on the wrist of a different patient who was of the same sex, race and approximate age and had died near the same time in the same hospital.
Demonstration of imputability or root cause:
Detected by the Tissue Bank