Transplant Program Shut Down After Man Gets Wrong Kidney

USC University Hospital puts kidney transplants on hold after mistake.

ByKATIE MOISSE, ABC News Medical Unit
February 18, 2011, 4:05 PM

Feb. 18, 2011— -- USC University Hospital has voluntarily shut down its kidney transplant program after a man was reportedly given the wrong kidney.

"No patient was harmed. However, as patient safety is the hospital's number one concern, the hospital inactivated the program while clinical protocols are assessed and additional safeguards to the kidney transplant program are developed," said Leslie Ridgeway, USC director of media relations, in a statement.

According to The Associated Press, the mix-up occurred after two kidneys from separate donors arrived at the transplant center simultaneously on Jan. 29 -- a Saturday. The program was immediately shut down.

"Our packaging and documentation was accurate," Thomas Mone, chief executive of the OneLegacy kidney transplant program told AP reporters, suggesting the mistake resulted from some human error.

The kidney which was transplanted, which had the universal blood type 'O,' was apparently a close enough match to avoid harming its unintended recipient -- a coincidence that experts say was lucky.

"They are all probably very relieved that this was blood group compatible," said Dr. Antonio DiCarlo, assistant professor at the University of Vermont College of Medicine and chief of transplant surgery at Fletcher Allen Healthcare. "This could have been devastating."

To determine whether an organ is a good match for a recipient, doctors perform a cross-match test, which involves mixing antibodies from the recipient with cells from the donor to determine if there will be an immune response. If nothing happens, the test is negative and the match is good. But if the cells react with each other, the test is positive, and moving forward with the transplant could kill the organ and possibly even the patient, DiCarlo said.

After USC realized its mistake, the organ procurement organization performed a cross-match test using blood samples they already had to determine the transplant's compatibility, the AP reported. The hospital then began looking for a suitable recipient for the other kidney -- the one the man should have received. That kidney was later transplanted at a local hospital.

The intended recipient of the misplaced kidney received another organ a few days later, the AP reported -- another fortunate coincidence.

"They [the patients] could have waited a year or six months before seeing an organ again," DiCarlo said. "We do realize that there's a mortality associated with being on a wait list, so the consequences for the person who did not get the organ could have been quite significant."

Communication Breakdown?

Kidney transplants are often performed on short notice and outside of normal hours, according to Dr. Daniel Salomon, associate professor at The Scripps Research Institute and co-director of the Center for Organ and Cell Transplantation at Scripps Green Hospital. And the number of people involved -- surgeons, anesthesiologists, nurses, transporters and patients (donor and recipient) -- make them a challenge to coordinate.

"This is never a direct one-on-one relationship between any two individuals," said DiCarlo, explaining the potential for miscommunication. "Especially when there are multiple organs coming in and multiple patients being seen, patients could be confused, names could be confused … and a wrong patient could be called in that was either on a separate list for a different blood group or lower down on the list."

But a series of safeguards are in place to prevent patients from receiving the wrong organ.

"The surgeon is ultimately responsible for making sure that the patient who's now in the operating room is indeed a patient on this list and is the patient that they wanted to be calling in from this list," DiCarlo said.

While USC reviews the incident, which involves the development of a corrective action plan in collaboration with the Network for Organ Sharing Department of Quality, the hospital is offering support to patients unable to receive kidneys through the university's program.

"Staff is providing assistance to patients on the kidney wait list by helping them get on kidney wait lists at other facilities, if that is their choice. Clinic appointments, testing and other patient care are continuing as scheduled," USC's Ridgeway said.

The review is set to be completed today, at which time they will consider reactivating the program, Ridgeway said.

The Associated Press contributed to this report.