Tag Archives: transplant

Hospital Acquired Condition

“Desensitization” Process Improves Compatibility of Donor Kidneys

By ThinkReliability Staff

Many patients with advanced and permanent kidney failure are recommended for kidney transplants, where a donor kidney is placed into their body. Because most of us have two kidneys, donor kidneys can come from either living or deceased donors. If a compatible living donor is not found, a patient is placed on the waiting list for a deceased donor organ. Unfortunately, there are about 100,000 people on that waiting list. While waiting for a new kidney, patients must undergo dialysis, which is not only time-consuming but also expensive.

Researchers estimate that about 50,000 people on the kidney transplant waiting list have antibodies that impact their ability to find a compatible donor kidney. Of those, 20,000 are so sensitive that finding a donor kidney is “all but impossible” . . . .until now.

A study published March 9, 2016 in the New England Journal of Medicine provides promising results from a procedure that alters patients’ immune systems so they can accept previously “incompatible” donor kidneys. This procedure is called desensitization. First, antibodies are filtered out of a patient’s blood. Then the patient is given an infusion of other antibodies. The immune system then regenerates its own antibodies which are, for reasons as yet unknown, less likely to attack a donated organ. (If there’s still a concern about the remaining antibodies, the patient is treated with drugs to prevent them from making antibodies that may attack the new kidney.)

The study examined 1,025 patients with incompatible living donors at 22 medical centers and compared them to an equal number of patients on waiting lists or who received a compatible deceased donor kidney. After 8 years, 76.5% of the patients who were desensitized and received an “incompatible” living donor kidney were alive compared to only 43.9% of those who remained on the waiting list and did not receive a transplant.

The cost for desensitization is about $30,000 and a transplant costs about $100,000. However, this avoids the yearly life-long cost of $70,000 for dialysis. The procedure also takes about two weeks, so patients must have a living donor. The key is that ANY living donor will work, because the desensitization makes just about any kidney suitable, even for those patients who previously would have had significant trouble finding a compatible organ. Says Dr. Krista L. Lentin, “Desensitization may be the only realistic option for receiving a transplant.”

The study discusses only kidney transplants but there’s hope that the process will work for living-donor transplants of livers and lungs. Although the study has shown great success, the shortage of organ donations – of all kinds – is still a concern.

To view the process map for kidney failure without desensitization, and how the process map can be improved with desensitization, click on “Download PDF” above. To learn more about other methods to increase the availability of kidney donations, see our previous blog on a flushing process that can allow the use of kidneys previously considered too damaged for donation.

 

Root Cause

Patient Wakes While Being Prepped for Organ Harvesting

By ThinkReliability Staff

An extremely rare but tragic case has been recently brought to light.  On October 16, 2009, a patient was brought to a hospital center in Syracuse, New York after suffering a drug overdose.  Over the next several days, the patient was in a deep coma, though she did not meet the requirements for brain death based on scans performed at the hospital.   The family was notified and agreed to donate her organs.  The patient, after being sedated, was prepped for donation after cardiac death (DCD).  The organ harvesting stopped prior to any organs being removed when the patient opened her eyes on the operating table.

The hospital was cited not only for the error, but for the inadequate response and investigation after the error was made by the state Department of Health and the Centers for Medicare & Medicaid Services (CMS).  Specifically, the CMS report states “The hospital’s Quality Assurance Performance Improvement program did not conduct thorough reviews of an adverse occurrence involving a patient who was being considered for withdrawal of life-sustaining treatment when she regained consciousness.”

We can examine the error using a Cause Map, or visual root cause analysis, to determine the issues related to the incident.  This provides a starting point for developing solutions to reduce the risk of such an incident recurring, and improving healthcare reliability at this site.

It’s important to frame the issue with respect to an organization’s goals.  In this case, the patient safety goal was impacted due to the risk of patient death from having organs removed.  The accidental removal of organs can also be considered an impact to the patient services goal.  The compliance goal is impacted because of the sanction and fine (though a minimal $6,000) from the Health Department.  Negative press and public opinion as a result of this incident – which was uncovered and reported to the Health Department by the press – is an impact to the Organizational goal.

Beginning with an impacted goal – in this case the Patient Safety goal – asking “Why” questions allows us to develop the cause-and-effect relationships that led to the issue.  In this case, the risk for patient death was due to risk of removing her organs.  The risk for removing organs is because the organ harvesting process had begun.  (The investigation did find that there were no concerns with the organ donation process itself, indicating that errors were prior to the donation prep process.)  The process began because the family agreed to donate organs after the patient was (incorrectly) determined to have suffered cardiac death.

There were a combination of errors that resulted in the patient being incorrectly declared “dead”.  Because all of these factors acted together to result in the impact to the goals, it is important to capture and fully investigate all of them to be able to improve processes at the organization.  In this case, the patient was injected with a sedative, which was not recorded in the doctor’s notes.  It is unclear who ordered the sedative and why.  (It’s also unclear why you would sedate a dead patient, as another doctor stated “If you have to sedate them . . .they’re not brain dead.”)  The patient had previously been in a deep coma due to the drug overdose.  It is possible the coma went on longer than usual because the patient was not given activated charcoal to inhibit absorption of the drugs by the body after the staff was unable to  unable to place a tube.  There appears to have been no additional effort – another area that should be investigated to ensure that protocol is sufficient for patient safety.

The hospital’s evaluation of the patient’s condition before a diagnosis of cardiac death was insufficient.  Specifically, it has been noted that the staff performed an inadequate number of brain scans, inadequate testing to determine the drug levels remaining in the body, and ignored signs that the patient was regaining consciousness prior to preparing her for organ donation.  Because details of these issues were not thoroughly investigated, it’s impossible to know whether the protocols in place at the organization were inadequate for determining cardiac death or whether the protocols were adequate and weren’t followed by staff.

Determining if changes need to be made to protocols as a result of this tragic (though I do want to emphasize rare – the state was unable to find any similar cases in its records) incident is of utmost importance to reduce the risk of an incident like this happening again.  Hopefully the additional scrutiny from the state and CMS will ensure improved patient safety in the future.

To view the  Timeline, Outline and Cause Map of this issue, please click “Download PDF” above.  Or click here to read more.

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

Transplant Recipient Dies of Lung Cancer After Receiving Smoker’s Lungs

By ThinkReliability Staff

After 18 months on the transplant list, a patient in England finally received a new set of badly needed lungs.  However, though required by NHS Blood and Transplant since March 2011, the medical history of the donor – specifically that the donor was a heavy smoker – was not disclosed to the recipient, who died shortly after of lung cancer.

The issues causing this death can be examined in a Cause Map, or visual root cause analysis.  We begin an investigation by determining which goals were impacted by the event.  In this case, the patient safety goal was impacted due to the death of the transplant recipient.  Additionally, patient services were impacted because the patient was given “higher risk” organs.  Lastly, the worldwide shortage of organs can be considered an impact to the property goal.  Once we have determined these impacts to the goals, we can ask “Why” questions to develop the cause-and-effect relationship leading to the issue.

The patient death was due to lung cancer.  The patient suffered from lung cancer because she received a lung transplant using lungs from a smoker.  The patient was unaware of the donor history though disclosure of the medical history of a donor is required.  Additionally, more patients are being given what are known as “higher risk” organs.  This includes organs from smokers, the elderly, and even drug users.  39% of lung transplants are from smokers.  Doctors believe that patients are better off with these organs than waiting on the transplant list.  Only a handful of transplant recipients have died from diseases related to their donors’ health, but every year about1,000 people in the UK die waiting for a transplant.  The quality of available organs is decreasing due to longer lifespan and obesity.  Additionally, the number of organs has always been less than needed.  The number of potential organ donors is small, due to a combination of factors, including personal reasons for not donating and families not donating a loved one’s organs when their wishes are not made clear.

Disclosure of a donor’s medical history is already required.  Increasing the number of donors is desperately needed to ensure adequate availability of organs.  You can contribute by becoming an organ donor and making your wishes clear to your family.  The medical profession is attempting to increase the usability of organs, using methods such as the one discussed in a previous blog.

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

Root Cause

More Known About Why A Donated Kidney Was Trashed

By ThinkReliability Staff

In a previous blog, we wrote about a donated kidney that was accidentally thrown out rather than being transplanted.  We began the root cause analysis investigation with the information that was available, but there were still a lot of open questions.

The Centers for Medicare & Medicaid Services (CMS) has released a report on the incident, which provides additional information we can use to update our Cause Map.  We can update all areas of the investigation, including updating any additional goals that were found to be impacted.  In this case, three employees had been placed on administrative leave.  Since the time of the previous blog, four employees have had their careers impacted – one has resigned, one has been fired, one has had a title removed, and another has since returned from paid administrative leave.  Additionally, there is a risk that the hospital may be removed from the Medicare program, another impact to the compliance goal.

The report provides more specific causes, and evidence, regarding the incident.  We know now that the kidney, which was to be transplanted, was instead thrown in a hopper by the circulating nurse.  We can ask “Why” questions to add more detail.  The kidney was thrown in the hopper because the contents of the slush machine were thrown in the hopper and the kidney was in the slush machine.  It still isn’t clear why the kidney was in the slush machine in the donor’s operating room (rather than being transferred immediately to the recipient’s room), but more information regarding the disposal is now available.

The nurse disposed of the hopper because she was unaware that  the slush machine contained the kidney.  The nurse had been on lunch break when the location of the kidney was announced and was not briefed on the status of the operation upon her return.  There was no documentation on where the kidney was located, and the nurse assumed that it was in the recipient’s room.  For reasons that are unclear (as it is usually the job of the technician who is responsible for the machine), the nurse decided to empty the slush machine while the operation was still ongoing.  This appeared to be against procedure, but the procedure had “exceptions” according to staff, and was ineffective in this case.  The technician that was responsible for the slush machine was exerting inadequate control, as the staff members have stated that no one noticed the nurse empting the slush machine.  This also demonstrates inadequate control of the kidney, since there appeared to be no staff person responsible for the kidney itself.

Since the incident, the hospital has developed a procedure for intra-operative hand-off, which includes a briefing requirement for staff members who enter an operating room mid-procedure.  Additionally, clarification has been provided that nothing will leave an operating room until the patient has left, post-procedure.  Although the transplant program is still shutdown pending investigation, a recommendation that might reduce this type of problem in the future would be to ensure that a staff member is designated as responsible for any donated organs from removal to transplant.

To view the updated Cause Map and potential solutions, please click “Download PDF” above

Root Cause Analysis

Donated Kidney Trashed

By ThinkReliability Staff

On August 10, 2012, a living donor’s kidney was thrown out, instead of being transplanted as planned.  The incident was chalked up to “human error”, which is almost certainly part of the problem . . . but definitely not all of it.

This extremely rare, but serious, event is being analyzed by several oversight agencies, as well as a contractor hired by the medical center in Ohio where the event took place, to ensure that needed improvements are identified and put into place so this type of incident doesn’t happen again.  We can examine the currently known information in a visual root cause analysis, or Cause Map.  To do so, we begin with the impacted goals.

There are many goals that were impacted as a result of this error.  Firstly, the patient safety goal was impacted because the patient did not receive the transplanted kidney.  This can also be considered an impact to the patient services goal.  Three personnel from the hospital were placed on administrative leave as a result of the incident.  This results in an impact to employees.  The compliance goal is impacted because this event has resulted in a review by several oversight agencies.  The living kidney donor program is currently shut down for review, which can be considered an impact to the organization goal.  The kidney was disposed of improperly, which is an impact to the environmental goal.  (Medical waste has strict requirements for disposal.)   The loss of the donated kidney can be considered an impact to the property goal.  Personnel time was taken both to attempt to resuscitate the kidney and to participate in an independent review of the donor program.  These can both be considered impacts to the labor/time goal.

Once we have determined the impacts to the goals, we can ask “Why” questions to develop the cause-and-effect relationships that led to these impacts.  In this case, the patient did not receive a kidney transplant because the kidney was thrown out and because of concern about the kidney’s viability.  Part of this concern was the delay in actually finding the kidney, likely due to the fact that it was disposed of improperly.  The reason given by the medical center for the disposal of the kidney is “human error”.  However, there is ordinarily a support system involved in organ transplants that would minimize these types of errors.  Certainly the fact that the program has been stopped and three employees – at least one of whom was not directly involved in the transplant operation – were placed on administrative leave suggest that the organization is looking at more than just a screw-up by one person acting alone.

Specifically, the investigation should look at communication – was the nurse who disposed of the organ told it was destined for transplant?  Was there a surgical time-out immediately prior to the removal with the entire operating team that discussed the plan for the kidney?  Also the training and preparation of the surgical team should be investigated.  Had the team been properly trained and prepped for this type of surgery?  The fact that it was done frequently at this facility doesn’t mean that adequate training was in place.  What about the procedure for treatment and supervision of donated organs?  Donated organs have to be treated in a very particular way to ensure their viability for the transplant patient.  Who, if anyone, was responsible for ensuring that the organ was prepared in a proper way for transplant?  Were they involved in the surgical time-out?  Lastly, because an error was made with the disposal procedure, the procedure, training and communication regarding disposal of medical waste needs to be analyzed to ensure it is adequate. The hope is that by doing a thorough review – and improvement – of policies, procedures, training and communication at the facility, it will not only reduce the risk of this type of error, but provide improvement in many other aspects of the care provided as well.

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

Never Event, Root Cause Analysis

Use of Contraindicated Clip Leads to Death of Kidney Donor

By ThinkReliability Staff

In 2011, a kidney donor in Texas bled to death after her renal artery became open.  Sadly, her death was associated with the use of clips to close the artery – rather than staples – even though the use of clips was contraindicated for this purpose.  The instructions that came with the clips said this, as did several warning letters sent from the manufacturer in previous years.

We can look at this tragic issue in a Cause Map, or visual root cause analysis.  We begin with the impacted goals.  Because of the patient death, the patient safety goal is impacted.  Emotional impacts from employees resulting from a patient death can be considered an effect to the employee impact goal.  The use of a device other than intended is a result to the patient services goal and is considered a “never event” (an event which should never happen), resulting in an impact to the compliance goal.  A lawsuit resulting from the patient death is an impact to   the organization goal.  A total of four kidney donors are known to have died as a result of using these clips.

We begin with the impacted goals and ask “Why” questions to understand the cause-and-effect relationships resulting in this tragedy.  The patient died from a massive, sudden bleed caused by the bleeding of the renal artery which was open.  The renal artery had been opened as part of the kidney donor surgery, and had been closed using clips that slid off the renal artery.  The stump remaining on the renal artery after this kind of surgery is too short to allow the clips adequate purchase, and the clips slid off.  The hospital staff was unaware that these clips were contraindicated for this use.  Although a warning was placed on the instructions for the clips, these instructions were not kept in the operating room.  Additionally, the manufacturer sent out several letters to hospitals warning them not to use these clips for kidney surgery.  However, at that time, this hospital was not using the clips, and had forgotten about the letters when the clips were purchased.

Once the causes related to the issue have been captured, possible solutions can be brainstormed.  In this case, there are solutions for all the stakeholders in the event.  The operating team should use staples instead of these clips to close the renal artery.  The FDA has issued a safety notification to attempt to provide additional warnings against using these clips after kidney donation.  The hospital has implemented a system to track and document warnings and recalls related to medical equipment.  Some personnel in the medical community have requested that the warning not to use the clips after kidney surgery are printed directly on the clips, rather than on the operating instructions.  Dr. Amy Friedman, the Director of Transplant Services at Upstate Medical University in New York, who had raised concerns about using clips in kidney donors starting in 2004, would also like the warnings to include information that donors have died as a result of using these clips.  Although the FDA believes that the warnings up to this point have been sufficient, hopefully the additional actions will prevent another death from the use of these clips.

To view the Outline, Cause Map, and Solutions, please click “Download PDF” above.  Or click here to read more.

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.

Root Cause Analysis

Technique Increases Availability of Donor Kidneys

By ThinkReliability Staff

Transplanted donor kidneys save lives, but availability does not meet demand.  Contributing to the problem is that some people who are willing to be donors have organs that are considered unsuitable for transplant.  A new procedure has been successful in making some of these previously rejected kidneys usable again.

The procedure involves flushing donated kidneys, which would previously have been rejected as unsuitable for transplant, with oxygenated blood (normothermic perfusion).  This can allow use of some damaged kidneys, such as those from the elderly or those with high blood pressure or diabetes.  It decreases the risk of a marginal organ being rejected.  It is believed that this could increase the availability of organs by about 500 a year in the United Kingdom, reducing the number of people on transplant waiting lists by about 10%.   (There are more than 6,400 kidney patients waiting for a transplant in the UK.)

So far, 17 organs that have been through the procedure have been successfully transplanted, between November 2010 and November 2011.  They are all functioning well.  The success of this procedure can be examined in a Cause Map, or visual root cause analysis.   Positive impacts to the goals can be examined in the same way that negative impacts are – by identifying the impacts and asking “why” questions to identify the causes.  Due to this procedure, the patient safety goal has been impacted by reducing the risk of rejected transplanted organs.  The patient services and material goal has been impacted by increasing the availability of donor kidneys.  And, the “labor” goal has been impacted by reducing the amount of time people wait for donor kidneys.

Beginning with these impacts and asking “why” questions, we can identify that the procedure is allowing the use of previously marginal organs by allowing treatment outside the recipient body and  reducing the risk of rejection.  This increases the number of organs that can be used, and since there are still more organs needed than available, this reduces the amount of time on the waiting list.

Although this procedure should increase the number of organs available and reduce time on the waiting list, it still will not provide enough organs for everyone who needs one.  Donor outreach to increase donors and family understanding of the life-saving organ donation process is still needed.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.