Report: Ohio nurse didn’t realize she took donor kidney
Monday, September 24, 2012
COLUMBUS, Ohio (AP) — A nurse who accidentally disposed of a living donor’s kidney during a transplant said she didn’t realize it was in chilled, protective slush that she removed from an operating room, took down a hall to a dirty utility room and “flushed down a hopper,” according to a report released by health officials on Monday.
The nurse said she didn’t realize the kidney was put in the sterile, semi-frozen solution because she had been on a break, with a different nurse in her place, when a surgeon made that announcement during the Aug. 10 transplant at the University of Toledo Medical Center, according to a review conducted by the state for the federal Centers for Medicare and Medicaid Services and obtained by The Associated Press through a records request.
Hospital administrative staff members interviewed on Aug. 21 hadn’t determined how the nurse took the 13-gallon bag of slush, meant to extend the kidney’s viability, past several members of the medical staff without them noticing a problem, the report said.
It said poor oversight and communication and insufficient policies were factors in the kidney’s disposal, which prompted the voluntary, temporary suspension of the hospital’s living-donor kidney transplant program and led to reviews by health officials and a consulting surgeon hired by the hospital.
The hospital, in northwest Ohio about 135 miles north of Columbus, “failed to provide adequate supervision and communication resulting in a donor’s kidney being carried out of the operating room, down a hall, into a dirty utility room, and flushed down a hopper,” the report stated.
The hospital has since enacted clearer policies to clarify communication between nurses who fill in for one another and to make sure nothing is removed from an operating room until the patient has been moved from it, the report said.
The hospital hasn’t said what happened to the intended kidney recipient, who was supposed to receive an organ donated by her brother. The intended recipient and her brother were released from the hospital, which didn’t identify them and said it couldn’t say whether she received a different kidney.
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