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In letter to employees, UH CEO addresses transplant error and lists actions taken

'Disappointed and distressed' by what happened
University Hospitals Cleveland Medical Center.
Posted at 2:40 PM, Jul 23, 2021
and last updated 2021-07-23 18:57:42-04

CLEVELAND — Nearly three weeks after University Hospitals caregivers transplanted a kidney that was intended for a different patient, the hospital system released a message to all employees acknowledging the error and explaining what they intend to do going forward -- to make “Zero Harm” its highest priority.

Read the complete statement sent Friday to all UH by Chief Executive Officer Dr. Cliff Megerian, MD, FACS, below:

All of us at University Hospitals are disappointed and distressed by the error in our transplant program that resulted in a patient receiving the wrong kidney and a transplant delay for a second patient. The incident resulted from a breakdown in following protocol during the organ verification process.

We recognize the pain this situation has caused our patients, their families, and also our caregivers. The error should never have happened, and it runs counter to the goals for safety and excellence we advocate throughout our health system. Thankfully, the patient has been released from our hospital and to this point is recovering well.

Our response to this event reveals the character of UH and our people. We promptly notified the patients and families involved about the error and apologized sincerely. We further pledged to investigate and take actions that strengthen quality and safety for all, which we have done and continue to do.

We also moved swiftly to notify the United Network for Organ Sharing, in its role as a government regulator overseeing transplant medicine, and we are working with the Ohio Department of Health and The Joint Commission. The lessons we learn from this event will be shared system-wide and with other health systems to improve safety everywhere.
We know that errors happen far too often in health care, and the causes are complex. The way we will prevent mistakes is through attentiveness to detail and dedication to a culture that puts safety first. Each of us, regardless of position, is accountable to speak up whenever we see a potential risk to the safety and wellbeing of our patients and each other.

We are fortunate to have Dr. Peter Pronovost, a nationally renowned leader in health care safety and change management, on our team. Even before the transplant event he was leading a campaign to instill Zero Harm as our clinical goal. This work continues.
Among our actions following the transplant event, we have:

· Established a Zero Harm executive cabinet.

· Reviewed our transplant policies and procedures, which have been modified to increase redundancy in the verification of organs and patients.

· Conducted training with appropriate transplant personnel that reinforces compliance with organ verification protocols.

· Initiated a project to determine the feasibility of incorporating bar code validation in organ verification.

· Expanded evaluation of the incident to include a broader assessment of our transplant program.

· Commenced the engagement of an expert third party to conduct a cultural safety assessment of the transplant program.

It is important that we honor the trust our patients place in us. I count on every UH caregiver to double down on quality and safety, and to always speak up. We are on a continuing journey to Zero Harm, because our patients’ lives depend on us.

Earlier this month, News 5 was first to report that there were two kidney transplants happening at UH on July 2. The health system confirmed a kidney meant for one patient was mistakenly transplanted into the wrong person. Fortunately, the person who received the wrong kidney seems to be accepting it and recovering, according to UH. Sources inside the hospital said the blood types were compatible.

News 5 investigators then learned the mistake wasn’t noticed until the second operation. UH wouldn’t confirm how far along the surgery was when the transplant team realized they had the kidney intended for the first patient. UH said the second patient is back on the transplant list awaiting another organ.

Two “caregivers" — UH would not disclose if they are doctors, nurses, or other staff — are off the job pending an investigation.

UH reported the problem to the United Network for Organ Sharing, the organization that oversees transplants in the U.S. We’ve also learned the Centers for Medicare and Medicaid Services is aware of the issue, is reviewing it, and will take appropriate action after the review.

So far, UH hasn’t answered how this could have happened or basic questions about the procedures. We asked UH for a sit-down interview and so far, representatives have refused.

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