Error sparks innovation at UTMC
10/14/2012THE University of Toledo Medical Center has deservedly faced a great deal of recent news coverage and public attention for the baffling discarding of a kidney that was to be transplanted.
In response, we have engaged our hospital staff — and we plan to engage medical centers across the nation — in an open discussion, using this incident as a case study to prevent future errors.
Based on our independent investigation and outside reviews, we continue to learn from this experience. And we are sharing what we have learned with others, in an effort to prevent this kind of unfortunate occurrence from ever happening again, at any hospital.
No amount of investigation and no new policy will reverse the painful reality created by this human error. But an open, candid, and transparent look at what changes UTMC can make as a result is a silver lining that needs to be pursued. As we look to the future, we will make sure that a measure of good follows from this error.
For 40 years, UTMC has transformed the lives of patients with end-stage renal disease. Among the 1,700 transplants UTMC has conducted, the survival rate is 98 percent.
The Toledo community has a transplant program it can be proud of. One of the primary reasons for that outstanding success rate is the effort we take to be innovative and to bring new, best practices and technology to the operating room.
In the past few weeks, we have placed infrared sensors in the operating room. Audible and visual warnings now sound and flash when someone reaches a predetermined distance from where a chilled kidney or piece of tissue is stored before it is transplanted in a recipient.
We are designing a cover that will sit magnetically on top of the metal basin that holds a kidney or tissue once it is removed from a donor. With a sterile sheet on top of the basin, this cover will need to be removed to gain access to an organ or tissue sample. Warnings will sound when it is removed, alerting everyone in the room.
No other operating room in the nation employs these fail-safe procedures. But we believe many will follow our lead in the near future.
In addition to this preventive technology, we have established stronger, more explicit policies on duties and responsibilities of care providers. They will remove any ambiguity during care transitions, such as when a patient is moved from the emergency room to the operating room.
We are using UT's Immersive Interprofessional Simulation Center to practice these new policies. They include specific checklists as medical staff shift care from one provider to the next. We plan to ingrain these additional safeguards into the standards of care of our doctors, nurses, and caregivers.
The central purpose of our simulation center is to teach today's students how to work in teams to give patients the best treatment. Our operating room is team-oriented: Surgeons, nurses, anesthesiologists, and specialists all play critical roles to ensure a successful procedure. Any person in the operating room has not only the ability but also the responsibility to ensure that proper policies are followed at all times.
Since the events of Aug. 10, I have met with many UTMC employees. They described to me the knot in their stomach that this error created, and the passion they have for the patients they are working to make well every day. Several have reached out to see what would be involved in donating one of their kidneys to the recipient.
The University of Toledo Medical Center is a better hospital today than it was two months ago. It will be better still two months from now. Health-care delivery is a human undertaking; as such, it will always be imperfect. When human errors occur, we will be honest and transparent. We will do everything we can to make things right.
But outside of those rare occasions, you will find an organization of thousands of people who are dedicated to creating a healthier community and improving lives in northwest Ohio.
Lloyd A. Jacobs, M.D., is president of the University of Toledo.