University of Toledo president admits flaws, renews pledge to patient safety

11/10/2012

University of Toledo President Dr. Lloyd Jacobs said an extensive survey at UT’s medical center, conducted this week and triggered by an August kidney transplant surgery error, found few issues and shows the hospital’s commitment to patient safety.

The Ohio Department of Health sent eight people to conduct the survey on behalf of the U.S. Centers for Medicare & Medicaid Services. On-site inspections and interviews occurred Monday through Thursday. Dr. Jacobs, during a Friday interview, said the hospital performed “wonderfully well” overall, but said he doesn’t trivialize the “very few” problems discovered. Surveyors gave a verbal report to officials; Dr. Jacobs said he did not know when a written report will be available.

The visit follows an Aug. 10 transplant incident in which a usable kidney was thrown out and rendered useless during a transplant procedure at the University of Toledo Medical Center, the former Medical College of Ohio. The hospital voluntarily ceased its live kidney donor program, as reviews and reports continue.

“I want patients who need our services and their families and our community to feel confident in our hospital and for them to have that confidence undermined by one inexplicable episode is hurtful to our overall community’s health,” said Dr. Jacobs.

Health department spokesman Tessie Pollock said a list of problems found during the survey won’t be released until the written report is done. Dr. Jacobs described the issues as five completed patient medical records that had not been signed within a 30-day required time limit, a microwave with food remnants in it, and a nurse who failed to wash her hands between glove changes.

“We need to fix them, and we learn from them, but that’s a... wonderful survey result,” he said.

Surveyors also found some building issues, such as a piece of concrete that required fixing, incorrectly placed exit signs, “very small holes” in a couple of fire walls, and a light switch that surveyors said was placed at the wrong height, Dr. Jacobs said. Surveyors also said some doors don’t meet fire-retardant standards, but medical center officials believe the doors do and will check into the situation, he said.

A previous review reported too-low humidity levels in some operating rooms, and the issue came up again during this week’s review.

Dr. Jacobs said there are “conflicting standards” about what the minimum humidity level should be. Some issues already have been corrected by pouring concrete, moving signs, and fixing holes.

When the final report is released officials will deal immediately with any issues that have not already been addressed, he said.

Dr. Jacobs said the survey results demonstrate the medical center's “abiding commitment to patient safety.”

Centers for Medicare & Medicaid Services spokesman Elizabeth Surgener wrote in an email that the recent survey work was authorized after an earlier surgical and transplant services survey found “the facility was out of compliance” with CMS conditions.

A health department report released in September and prepared for CMS found the medical center disregarded several policies during the botched kidney transplant.

This week’s survey was unannounced, but hospital officials anticipated the visit at some point. CMS awaits results of the state’s recent survey and “will work with both the state and the facility on next steps,” Ms. Surgener wrote.

Dr. Jacobs said the living-related donor program will be reinstated upon advice of the United Network for Organ Sharing, which will consider the matter at an early December meeting.

“We’ll wait until the agency says, ‘We think you are in good shape.’ We believe we are in good shape, but we’d like to hear from them,” he said.

Contact Vanessa McCray at: vmccray@theblade.com

or 419-724-6065.