The UPMC kidney transplant story continues to develop. This was the one where a doctor and nurse were disciplined in a matter that clearly reflected some systemic problems, more than personnel problems regarding those two people.
Now UPI reports:
A report by a federal agency on a kidney transplant at the University of Pittsburgh Medical Center suggests more problems than the hospital has acknowledged.
The Centers for Medicare and Medicaid Services said its investigation found the nephrologist should have been aware the kidney donor was infected with hepatitis C, the Pittsburgh Post-Gazette reported Tuesday. The hospital has suspended the lead surgeon and the transplant coordinator.
The CMS report said the test results were available for two months in the donor’s medical record. But none of the doctors and nurses apparently reviewed the record, and the kidney was transplanted into a man who was not infected with the virus.
The story concludes in a manner that feels like an oxymoron with regard to confidence:
Dr. Abhinav Humar, the head of the UPMC transplant coordinator, said he is confident the hospital has developed appropriate corrections for its failures.
Wouldn’t it be great if UPMC would tell the whole story and help all the transplant centers in the world understand the nature of the problems that occurred, so all could benefit from this experience and improve programs worldwide?
Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.
It’s sad that in our days mistakes like that are made. But we are humans, problems may appear.