Response planned to transplant investigation

9/26/2012

University of Toledo Medical Center officials are preparing a formal response to an Ohio Department of Health report that details how a viable kidney was lost last month during a botched transplant.

Larry Burns, UT's vice president of external affairs, said the university will deliver the response to state and federal agencies reviewing UTMC's live-organ donor program in an upcoming meeting. The response will then be made public. After the meeting, there will be more action by one of those agencies, the Centers for Medicare & Medicaid Services, according to a statement.

"The state survey agency will conduct a full, unannounced review of the hospital in the coming months to ensure that there are not additional deficiencies," according to the statement.

The health department report, made public Monday, detailed how a usable kidney was discarded Aug. 10 at the former Medical College of Ohio Hospital before it could be transplanted into the donor’s sister. The hospital voluntarily suspended live-donor kidney transplants after the incident and disciplined several employees, including two nurses involved in the surgery.

Judith Moore, a part-time nurse, resigned Sept. 10 after her suspension, and university officials said Monday that Melanie Lemay, a full-time nurse, has been fired. Edwin Hall, administrator of surgical services, was notified Aug. 27 that he would be on "paid administrative leave" but was reinstated to his job on Sept. 14.

According to the report, a nurse went on break during the Aug. 10 transplant and was relieved by another nurse. While the first nurse was away, the kidney was removed from the patient, wrapped in a lap sponge, and placed in a surgical “slush machine,” which is used to keep organs cold during transplants. The second nurse, a scrub technician, and two physicians were in the room when the kidney was removed and knew of its location.

The first nurse returned to the operating room and removed the contents of the slush machine, eventually flushing it down a hopper. She didn’t ask anyone what had happened while she was away, and no one told her, according to the report.

The report also detailed two other incidents with insufficient documentation about the location of a kidney or time a kidney entered an operating room. Despite the errors, Mr. Burns said he wasn't concerned that the hospital has a problem with improper oversight of programs "because of our long-term, overall record." "It doesn't mean that we don't always look how to get better," he said, "but we stand by our record in this program and other programs."

Mr. Burns said he didn't know why Dr. Michael Rees, who was the surgeon; the anesthesia resident; and the scrub technician haven't been disciplined. He also said he didn't expect any senior hospital leaders to face any discipline.

The University of Toledo and a Dr. Rees-led program called the Alliance for Paired Donation Inc. received a competitive, $2 million federal grant shortly before the botched transplant. The U.S. Agency for Healthcare Research and Quality grant was to develop a four-year pilot program to increase the pool of available kidney donors. An agency spokesman said the grant's status has not changed.