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Wrong Patient Receives Organ From Methodist Medical Center

By Jason Allen and Matt Goodman, CBSDFW.com
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CBS DFW (con't)

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DALLAS (CBSDFW.COM) – The kidney and pancreas transplant program at Methodist Medical Center has been put on hold after a patient was given a kidney meant for someone else, a hospital spokeswoman confirmed.

Kathleen Beathard, Methodist Health System’s Vice President of Public Relations, said the patient in question is OK and suffered no complications during surgery. But the mismatch, which an investigation has deemed to be a ‘human error,’ has alarmed hospital officials enough to make them halt the 31 year old transplant program.

“Last week however we discovered an incident where, because of human error, our process of matching a donor identification number with a recipient’s name was not followed,” Beathard said.

In the error’s wake, the hospital has reached out to more than 3,000 patients who have gone through the program and notified them of the error. For 2011, the hospital says there have been 58 total kidney transplants, including 47 single kidney operations, two kidney and pancreas operations and nine liver and kidney transplants.

The hospital learned about the mistake within the last few weeks. Beathard said the internal investigation has identified new protocols to keep the error from happening again.

One past patient called the error “unfathomable.” Tia Davidson needed a kidney and a liver in 2010. When other hospitals wouldn’t or couldn’t perform the operation, surgeons at Methodist stepped in.

“When everyone else said I didn’t have a chance, they took a chance on me and saved my life,” Davidson said in December 2010.

Davidson is one of the patients who Methodist will notify about the error. On a phone call from Montana, she said she held the program in the highest esteem.

“They were nothing but professional and thorough. That’s why it’s just so strange to me they could chalk it up to just a simple error because there are so many checks and balances, so many people involved,” Davidson said.

The United Network for Organ Sharing, which is under contract with the federal government to manage the country’s organ transplant list, also confirmed that Methodist voluntarily put its program on hold.

“Such inactivations sometimes occur when a transplant institution identifies a need to study and possibly correct procedures for the benefit of its patients,” UNOS spokesman Joel Newman said in an email.

That’s different from when a program closes or “withdraws” from the network.

“This would mean the program has no short-term intention to reopen. Patients would be notified and given assistance to transfer to other programs without losing any priority they had at the existing program,” Newman wrote.

The 208 patients on the kidney and pancreas transplant list will not lose their place in line because of the inactivation. Newman said they’ll be allowed to have the transplant at another hospital.

Liver transplants are not affected by this.

Here’s a statement the hospital released Thursday afternoon:

For 31 years, the Methodist Dallas Medical Center Transplant Program has provided the highest quality of care, safety and service for our donors and recipients as evidenced by our consistently high patient and graft survival results. Last week, however, our team discovered a recent incident where, as a result of human error, our process of matching the donor identification number to the recipient’s name was not followed. While Methodist’s standard safety verifications kept the recipient of the organ safe, this occurrence did not meet our commitment to provide the highest quality of care, safety and service for our donors and recipients.

We took immediate action to begin an internal review to determine the root cause and put additional protocols in place to ensure the continued safety of our patients. Our foremost commitment is to our patients and we will work diligently with the United Network for Organ Sharing (UNOS) to resume the life-saving work in caring for our kidney and kidney/pancreas transplant patients very soon.

Beathard said the transplant program will resume following a UNOS review of the situation and its protocol changes. Hospital officials did not release specifics on those changes Thursday.

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