A Mystery At Philadelphia's Jefferson: 52 Surgeries, Nine Deaths

oramar · Jun 3, 2003

Interesting, I can see why suspicion is falling on surgeon. I would not know enough to point the finger myself.

HoJo · Jun 8, 2003

Sounds like more than just the surgeons fault.

DeBerry had trouble understanding the five-page report on the procedure performed by Ratner and Dafoe, but certain things struck her. There were references to the breaking of a surgical retractor, a tool used to hold open the area being operated on; extensive bleeding; and a saw breaking when surgeons tried to cut open the chest to massage his failing heart. Ultimately, he died because his heart stopped pumping properly

Home Health Columnist / Guide · Jun 14, 2003

State and federal inspectors are evaluating the liver-transplant program after 9 deaths.

By Stacey Burling and Susan FitzGerald

Inquirer Staff Writers

http://www.philly.com/mld/inquirer/living/health/6059101.htm

Pennsylvania and federal health inspectors are conducting an unannounced review of the liver-transplant program at Thomas Jefferson University Hospital.

A team from the Pennsylvania Department of Health and the federal Centers for Medicare and Medicaid Services started their survey at the hospital Monday, spokeswomen for the hospital and federal centers said.

The survey, aimed at evaluating the quality of care and compliance with state and federal regulations, was prompted by an Inquirer story on June 1 about deaths during or immediately after liver transplants at Jefferson, said Jennifer Olsen, spokeswoman for the federal centers.

Between October 2001 and last month, eight liver-transplant patients at Jefferson died in the operating room and a ninth died within hours of surgery. The hospital did 52 transplants during the 20-month period. That is a death rate during or immediately after surgery of about 17 percent.

Nationally, in the last three years, fewer than 2 percent of liver-transplant patients died during surgery or within 24 hours of their operations, according to the Scientific Registry of Transplant Recipients, a national research organization.

Olsen said she did not know when the state and federal inspectors would finish their review at Jefferson.

Jefferson officials have said that they looked carefully at each of the transplant deaths and found no problems. They said it was not valid to focus on deaths at the time of surgery. Researchers typically look at survival at a month or longer. By those measures, they assert, their program falls within national norms.

In response to a complaint, the state health department investigated the liver-transplant program last October and found no deficiencies in patient care, the hospital said. The department cited the hospital for not notifying it of operating-room deaths from 2001 and 2002.

Richard McGarvey, a spokesman for the state health department, said yesterday that federal health officials asked the state last week to join them for the Jefferson survey.

Olsen said the state was conducting the survey while employees of the federal centers observe. Included in the team is the regional organ-transplant coordinator of the federal centers, whose job is to ensure that transplant facilities in 16 states comply with Medicare and Medicaid rules.

"Our goal in doing this is to ensure patient safety and patient quality of care," Olsen said.

Jefferson is one of three liver-transplant programs in the area with Medicare approval, meaning Medicare will pay for liver transplants there. If serious problems were found, the federal centers could withdraw that approval, Olsen said. Short of that, the hospital would be asked to submit a plan to address any problems the survey team identified.

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Contact staff writer Stacey Burling at 215-854-4944 or [email protected].