Tag Archives: patient death

Root Cause

Rabies From Donated Kidney Kills Recipient

By ThinkReliability Staff

A kidney donation recipient died in February, 2013.  It was determined that his death was due to rabies – specifically rabies that had been transferred with the donated kidney during the transplant in September 2011.  Although infectious disease transmission through transplant – especially rabies – is rare, there is benefit in visually diagramming a root cause analysis of this event in a Cause Map.   A Cause Map begins with the specific impacts to an organization’s goals resulting from an incident, and shows the cause-and-effect relationships that led to those impacts.

In this case, the patient safety goal was impacted due to the recipient death.  The receipt of organs infected with a disease such as rabies is an impact to the patient services goal.  Three other recipients also received organs from the same donor but have not shown symptoms of rabies.    Their treatment is an impact to the property and labor goals, due to the cost, time and inconvenience of those treatments.

The impacted goals form the first cause-and-effect relationship in our Cause Map.  We ask “Why” questions to determine other cause-and-effect relationships.  In this case, the donor death was due to rabies.  The donor was infected with rabies from an infected transplanted organ, and was not treated for rabies.  The recipient was not treated for rabies as the symptoms did not emerge until a year after the transplant (rabies can have a long incubation period).  The donor organs were infected with rabies from an unknown cause, though rabies usually results from contact with wild animals (specifically, this strain of rabies appears to be from a raccoon).   The transplant medical team was unaware that the donor had rabies.

Though the donor had encephalitis, it was thought that it was due to a food-borne illness.  (Detail on how the diagnosis was obtained has not been released.)  While there is testing for certain diseases performed on donor organs, due to the time constraints on the viability of the organ, testing for rabies is not generally performed.  However, new guidance from the Disease Transmission Advisory Committee (put out after this donation occurred) urges caution in use of organs from donors with encephalitis, perhaps including more robust testing for specific illnesses, or using only certain organs.

Due to an acute shortage of viable donated organs, some believe that organs from disease-positive donors should be used, and treatment started immediately.  With many in need of transplants dying on the waiting list, this may be a more practical approach, though there are certainly concerns about transmitting diseased organs to those who are already very ill, and who will be taking immune suppressing drugs to prevent rejection of transplanted organs, making them more susceptible to such diseases.

To view the Outline and Cause Map, please click “Download PDF” above.

Read our previous blog about a recipient who died of lung cancer after receiving the lungs of a heavy smoker

Root Cause Analysis

Living Donor Dies During Liver Transplant

by ThinkReliability Staff

In May 2010, a living liver donor died on the operating table.  Investigation showed that there were multiple issues related to the patient’s death.  The clinic was cleared of any wrongdoing in the death – and the surgeons there don’t believe that the surgical issues contributed to the death – but the clinic was cited for  violating rules designed to inform and protect donors.

We can look at all the related issues and see the cause-and-effect relationships in a Cause Map, or visual root cause analysis.  We begin with the impacts to the goals.  The patient death is an impact to the patient safety goal.  Patient deaths also cause impacts to related employees, which is an impact to the goals.  The citation for the violation of donor protection rules can be considered an impact to the compliance goals.  As a result of this incident, the clinic voluntarily stopped operations on living donors for 4 months, which can be considered impacts to the schedule and customer service goals.  Once the impacts to the goals are determined, we can begin with an impact and ask “why” questions to add detail to the Cause Map.

The patient death was determined to be due to a combination of cardiac arrest and excessive bleeding.  The cardiac arrest occurred because the patient’s heart was too weak to withstand surgery, and the patient was undergoing surgery.  The patient was donating a portion of his liver as a “living donor”.  Because the patient was not properly informed prior to his surgery, it’s unclear whether he would have continued if proper processes had been followed.  Donors are required to be given outcomes from both the site performing the surgery and national results.  The information the donor received was not up-to-date, as the paperwork had not been updated.   Additionally, because the donor’s needs may be opposite of the recipient’s needs, the donor’s advocate is required to be involved only in the donor’s care.  In this case, the advocate was also involved in the recipient’s care. Lastly, the patient received an abnormal EKG (which indicated that he may have had a prior heart attack) during his operation prep.  Although later testing showed that there was no reduction in blood flow to the heart, it’s unclear whether the patient was aware of these results or in a cardiologist was consulted.  The patient did not request a second opinion to determine whether or not he was healthy enough to handle the surgery.

Excessive bleeding occurred during the surgery and was thought to also have contributed to the patient’s death.  Bleeding occurred because the patient was in surgery.  Because the type of surgery the patient was doing is relatively new, it’s also possible that the surgeon’s lack of familiarity with the surgery may have contributed to the bleeding.  The bleeding wasn’t able to be stopped because it was difficult to find the multiple sources.  The patient was having laparasopically assisted surgery, which results in a quicker recovery time for the patient but also means that the bleeding source needs to be found through small holes, rather than one large incision.  Although the surgeons say it was not related to the patient death, a high speed blood pump was not used, though it was available, and the procedure for massive bleeding was not followed.

Whether or not these issues contributed directly to the patient’s death, they should still be reviewed as sources of improvement for the facility.  Other facilities as well can use this incident to examiner their own procedures and look for opportunities to increase patient safety.

To view the Outline and Cause Map, please click “Download PDF” above.