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Transplant error, nurse and doctor disciplined.

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by oramar oramar (Member)

oramar works as a returned nurse.

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upmc disciplines 2 members of kidney transplant team

thursday, may 26, 2011

by jonathan d. silver, pittsburgh post-gazette

upmc today confirmed it has disciplined a surgeon and a nurse involved in a kidney transplant earlier this month in which a positive test result for hepatitis c in the live donor that might have stopped the surgery was missed by the medical team until it was too late.

in addition, the hospital system said it has voluntarily suspended its prestigious live-donor liver program as a precaution. upmc temporarily shut down its live-donor kidney program following the hepatitis c snafu.

that program remains closed.

http://www.post-gazette.com/pg/11146/1149362-100.stm

Edited by NRSKarenRN

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14,790 Visitors; 991 Posts

I wonder who Ms Yates is related to in that healthcare system?

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merlee has 36 years experience and works as a nursing.

2 Likes; 13,255 Visitors; 1,246 Posts

Ouch. How did they miss the positive results?

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tewdles has 31 years experience.

30,575 Visitors; 3,156 Posts

wow...just wow.

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diane227 has 32 years experience and works as a I am about to embark on a new adventure as a state.

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Perhaps my expectations are too high but it seems like common sense to check all your lab results before doing any type of transplant, along with the donor history.

Same goes for surgery. How the hell do you operate on the wrong body part?

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NRSKarenRN has 40 years experience as a BSN and works as a Registered Nurse, Home Health.

105 Likes; 5 Followers; 7 Articles; 159,044 Visitors; 14,359 Posts

philly's temple in same dill pickle:

from phila inquirer, may 25th 2011

pa. health dept. cites temple's transplant programs for failing to meet medicare rules

by stacey burling

inquirer staff writer

the pennsylvania department of health has cited four of temple university hospital's transplant programs - lung, kidney, heart and liver - for failing to meet federal rules for participating in medicare.

in a report posted recently on its website, the state said temple's lung- and kidney-transplant programs had lower-than-expected one-year graft survival rates. the graft is the transplanted organ. patients may still be alive if they received another transplanted organ.

the state also said temple had done too few heart transplants. in a less-serious violation, the state said temple's liver-transplant program had failed to keep some patients informed of their status on the transplant waiting list. ..

..rebecca harmon, director of public relations for temple university health system, said the kidney program had not been flagged for any problems with patient survival. "our practice is to complete an in-depth analysis of every graft failure and make changes, as appropriate - which is what we did during the period reviewed in the cms report. . . . as a result, the program continually achieves improved processes though ongoing performance-improvement activities." this month, temple said it would voluntarily inactivate its lung-transplant program friday because its primary lung-transplant surgeon was leaving for another job. ...

temple putting lung-transplant program on hiatus

..at penn - now the area's dominant transplant program - surgeons in 2010 did 61 heart, 52 lung, 115 liver, and 162 kidney transplants.

hahnemann also has had relatively low volume in its heart-transplant program, with 10 transplants in 2008, nine in 2009, and 11 last year. it has done no heart transplants so far this year. howard eisen, chief of the division of cardiology, said that transplants were not spread evenly throughout a year, and that he was confident the numbers would rise....

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cherryames1949 has 27 years experience and works as a home health.

9,493 Visitors; 347 Posts

The same thing happened at Duke a few years ago. They transplanted the wrong organ. Yikes! Mistakes will always happen as long as human beings are involved. We can only try to learn from these errors. Obviously we have much more work to do.

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14,790 Visitors; 991 Posts

I'm making an observation here. I'm noting all the years of experience of the above nurses commenting on this article, myself included. We are the ones rather perplexed that something so basic to the unit of speciality would be overlooked. If I'm reading this correctly- wouldn't hepatitis status be an no brainer basic standard of care? Did this kind of mega oversite go on in our day?? I realize that transplant is on a more sophisticated level than back in the 80's-90's but it seems our OR charts were more thoroughly gone over back then so this kind of thing didn't happen. Is it the pace, the staffing levels or the lack of attention to the basics, or the lack of processes of old that are no longer inplace- tossed out to make way for the new and improved. That rah! rah! rah! for technology and 'ours is better than yours' mind set.

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Ginger Snapp works as a HELPING OTHERS {~ *}.

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SCARY

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its an awful thing to know despite of our modern techniques! indeed medical error is still one of humans coz of death :o

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sunkissed75 works as a Full-time Mom and PSW (similar to a CNA).

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But, look at the trickle down effect of this.... because the live-donor programs have been suspended other people in need are now being affected by this mistake as well. How long is the suspension going to last and what will happen to the people left waiting?

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blueheaven works as a RN.

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upmc disciplines 2 members of kidney transplant team

thursday, may 26, 2011

by jonathan d. silver, pittsburgh post-gazette

upmc today confirmed it has disciplined a surgeon and a nurse involved in a kidney transplant earlier this month in which a positive test result for hepatitis c in the live donor that might have stopped the surgery was missed by the medical team until it was too late.

in addition, the hospital system said it has voluntarily suspended its prestigious live-donor liver program as a precaution. upmc temporarily shut down its live-donor kidney program following the hepatitis c snafu.

that program remains closed.

http://www.post-gazette.com/pg/11146/1149362-100.stm

my husband just completed a liver transplant workup and upmc was going to be the center to perform the surgery. i am the wrong blood type for a live transplant. his meld score isn't high enough at this time. he will need a cadaver liver. i really feel bad for those who are waiting for an organ.

honesty by potential donors would go a long way too. one thing that doesn't always get asked is if they are a veteran from the viet nam era. if they are, there is a good chance they may have contracted hep c.

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