The source of the error(s) with the Duke transplant

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1: If the surgeon had double checked the organ match, this would have been avoided.

2: The donor organs were labeled correctly

3: Somewhere at Duke, there was an initial error whereby Jesicas type match was not reported correctly to UNOS.

UNOS uses a computerized matching algorithm, so for UNOS to contact Duke and tell them that they had a matching organ set indicates that Jesicas type match was somehow misreported to UNOS. Otherwise, the error would be in the computer program UNOS uses.

I think most people would agree that the surgeons at duke screwed up by not double checking the match, which is standard medical practice, thereby making them guilty of malpractice.

The real question is where did the initial error occur? If Jesicas type match had been reported correctly to UNOS, then this would not have happened. We know there were at least 2 errors that occurred, but Duke never explained how the initial mismatch happened. Anybody care to speculate?

From my understanding, jesica was entered on the patient list for UNOS 3 years ago. I'm assuming thta basic info regarding her organ/blood type match was also entered at the same time. So this error could be over 3 years old.

Another question is who is responsible for reporting info to UNOS? Was it the doctor who ordered the original tissue type match test who then reported this info to UNOS? Was it the same surgeons who did the transplant surgery or someone else?

 

[VienneseWaltz]

The organs arrived at Duke for another patient. The surgeons rejected the organs for transplant in that particular case. Another patient at Duke was considered. The surgeons rejected them for that patient, too. Somebody suggested Jesica, so apparently, in the excitement, they forgot to check to see if she was a match.

 

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Originally posted by VienneseWaltz
The organs arrived at Duke for another patient. The surgeons rejected the organs for transplant in that particular case. Another patient at Duke was considered. The surgeons rejected them for that patient, too. Somebody suggested Jesica, so apparently, in the excitement, they forgot to check to see if she was a match.

Wow I didnt know antying about other patients being involved. Well that makes the surgeons at Duke look worse than they might have otherwise.

 

[VienneseWaltz]

Duke does a LOT of transplants (I volunteer in their surgical ICU), so I'm pretty sure they have several transplant teams. I think (but I'm not sure) that the surgical team for whom the organs originally arrived were not the same team that transplanted them into Jesica. I don't think Jesica's team ever knew the organ blood type until the surgery was done.

 

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I thought if the surgeons rejected the organs, that they automatically have to go to the next patient on the list (i.e. not be diverted to some other patient who isnt even on the same match list)

UNOS probably needs to change their policy to state that if a transplant team rejects an organ then that organ MUST go to the next person on the list, not get diverted to some other patient that UNOS doesnt show as a match to the organs.

 

[cg1]

Repost much?

Hello? 😀

 

[VienneseWaltz]

You can't just ship organs all over the place. They have to be transplanted within a certain time frame. First dibs goes to the highest match on the list. If they are rejected for transplant once they arrive, they go to the closest match. If no matches are close and the organs are still viable, then, yes, probably, they go to the next person on the list, but if a match is nearby, the organs stay put. These decisions take place within hours, if not minutes, of each other--there's no time to fly them all over a region.

 

[VienneseWaltz]

BTW, organ donation tends to take place within geographic regions (except in special cases, e.g. a perfect match, including all minor antigens). If a donor dies in Georgia, even if a match in California is in slightly more critical condition, it will probably go recipient nearby, say, in NC. This is my understanding of the system from a friend who did a transplant rotation.

 

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This is my guess of how the conversation between UNOS and Duke went:

UNOS: Hello, this is UNOS, we have an organ match for patient X.
Duke: OK, we are declining that patient.
UNOS: OK, the next patient match is for patient Y.
Duke: We are declining that patient too. However, we have another patient that we would like to match.
UNOS: OK, the organs will arrive at your location shortly.

What SHOULD have happened would be somethign like this:

UNOS: We have an organ match for patient X
Duke: We are declining that patient
UNOS: OK, the next patient match is Y.
Duke: We are declining that patient too. However, we want to take the organs to match with another patient.
UNOS: Who is this patient?
Duke: Her name is Jesica Z.
UNOS: Umm...according to our match list, there is no patient named Jesica who matches to these organs

What I'm saying is that UNOS should be more central to the process of organ-patient matching. They should know which organs are going to which patients.

 

[VienneseWaltz]

Surgeons can and do decline the organs AFTER they arrive, which is what happened at Duke, sometimes even early in the surgery (obviously, before the old organs have been removed). I don't know the medicine involved, but I assume there are some things that a surgeon can't make a judgment on until the organs are actually there in the hospital. Sometimes, a patient's condition can deteriorate past the point of a operability while the organs are in transit. I see your point, that UNOS should be involved at every step, but I think there just isn't that much time, especially when the organs come with paperwork. The source of the error is not that they went ahead without checking with UNOS--it's that a series of people did not check the paperwork, which clearly stated the blood type of the organs. I think there are other safety measures that would be more efficient than calling UNOS before every decision.

 

[Samoa]

The story as I heard it on the news was that they had to remove Jessica's heart and lungs before the organs even arrived, and that they did not know it was not a match until they got there, and by then they had no choice but to transplant them anyway or Jessica would have died on the OR table.

So the decision to transplant them into Jessica had to have been made while the organs were still at the donor's hospital.

Also, it's entirely possible that the blood type was entered incorrectly at the donor site. That information is entered manually into the UNOS computer from the donor site via the web (I've watched it being done by a member of my old hospital's donation team), and it's entirely possible that the medical records accompanying the organ were correct, yet the information upon which the match was based was not.

 

[VienneseWaltz]

Pretty speculative. I have never heard of organs being removed before the replacements had arrived, and anyway, the organs were already at Duke for another patient (I volunteer there & it's the only thing on the news in Durham).

It has been verified that the donor organs were correctly typed from the beginning.

 

[Samoa]

I'm just repeating what was in the news. I don't find it at all difficult to believe that the organs would be removed before the donor organs arrive. The surgery to remove the old organs is long, as is the surgery to implant the new ones, and the donor organs have a short viable period after harvesting. If they have to be flown anywhere, the recipient basically has to be ready to accept them as soon as they arrive, which means the old organs have to be out.

This is not speculation on my part: I worked as a pharmacist in the ICU where the heart, lung, liver and kidney transplant patients would spend their first few days after surgery, and where the donors would spend the hours before harvesting. I used to spend my down time on the job reading Operative Reports, Progress Notes and other stuff in the patients' charts. And chatting with the nurses and residents.

 

[VienneseWaltz]

I've found conflicting reports. You might be right about her organs' being removed to soon--I found an unconfirmed report that suggests it might have happened. I knew that surgery might get started before new organs arrived, but I didn't think they would go so far as to actually remove the old organs--I mean, what if something caused the plane to get delayed, etc?

The report that the organs had already arrived for another patient conflicts with other reports I found saying that they were flown in for Jesica.

What I meant was speculation is the suggestion that the donor type was incorrect at some point.

 

[VienneseWaltz]

Last week they reported on the news (or NPR, I don't remember) that the organs were at Duke already, which would explain a hasty decision ... That doesn't appear to be the case--so you're right , Samoa. From what I've read, it seems that Carolina Donor Services bears some responsibility for this. They WERE contacted before the organs were approved for Jesica ... everyone is so focused on Duke (which admits to failing to double-check the match), but CDS seems to have made the original mistake ...

 

[MacGyver]

Originally posted by VienneseWaltz
The source of the error is not that they went ahead without checking with UNOS--it's that a series of people did not check the paperwork, which clearly stated the blood type of the organs. I think there are other safety measures that would be more efficient than calling UNOS before every decision.

this would have been avoided if Duke relied on the UNOS match algorithm instead of diverting it and circumventing the match process

 

[omores]

Originally posted by Samoa
The story as I heard it on the news was that they had to remove Jessica's heart and lungs before the organs even arrived, and that they did not know it was not a match until they got there, and by then they had no choice but to transplant them anyway or Jessica would have died on the OR table.

Much as I like this version of events, according to my friend who was actually on that transplant team (though she wasn't scrubbed in for that particular surgery), the surgeons didn't know the organs weren't a match until the very end of the operation.

 

[MacGyver]

Originally posted by VienneseWaltz
You can't just ship organs all over the place. They have to be transplanted within a certain time frame. First dibs goes to the highest match on the list. If they are rejected for transplant once they arrive, they go to the closest match. If no matches are close and the organs are still viable, then, yes, probably, they go to the next person on the list, but if a match is nearby, the organs stay put. These decisions take place within hours, if not minutes, of each other--there's no time to fly them all over a region.

A 2 minute phone call to UNOS would have avoided this whole situation.

 

[MacGyver]

Originally posted by VienneseWaltz
Last week they reported on the news (or NPR, I don't remember) that the organs were at Duke already, which would explain a hasty decision ... That doesn't appear to be the case--so you're right , Samoa. From what I've read, it seems that Carolina Donor Services bears some responsibility for this. They WERE contacted before the organs were approved for Jesica ... everyone is so focused on Duke (which admits to failing to double-check the match), but CDS seems to have made the original mistake ...

Duke bears sole responsibility for this screwup. When a branch of UNOS offers an organ and you take it (but divert it to another patient) then it becomes the SURGEONS responsibility to ensure proper type matching.

If you take an organ from UNOS and divert it to another patient, UNOS's responsibility for type matching ends right there.

The only way UNOS would be responsible is if their computer match algorithm had faulty information in it. This was not the case. Jesica was never on the UNOS match list for that organ set.

 

[MacGyver]

the donor organ information was correct and the paperwork accompanying it was correct also.

UNOS (the carolina agency) did nothing wrong here. They never matched the organs to Jesica, they matched them to another patient who was a bona fide match.

Once the donor organs were shipped to Duke, UNOS responsibility ends right there. The only way UNOS could be held at fault is if they supplied wrong match information to Duke. That did not happen here.

 

[MacGyver]

Originally posted by Samoa
The story as I heard it on the news was that they had to remove Jessica's heart and lungs before the organs even arrived, and that they did not know it was not a match until they got there, and by then they had no choice but to transplant them anyway or Jessica would have died on the OR table.

Sorry I dont buy that at all. The Duke people knew that UNOS matched the organ set to another patient, they knew what that other patient's tissue type/blood match was. To claim that they had no choice and that they had no way of knowing what the organ type match was before it arrived is just plain wrong.

So the decision to transplant them into Jessica had to have been made while the organs were still at the donor's hospital.

Thats fine, but its NEVER OK to just go ahead without ensuring a proper tissue match.

Also, it's entirely possible that the blood type was entered incorrectly at the donor site. That information is entered manually into the UNOS computer from the donor site via the web (I've watched it being done by a member of my old hospital's donation team), and it's entirely possible that the medical records accompanying the organ were correct, yet the information upon which the match was based was not.

Thats not what happened here. The donor organ information was correctly entered into the UNet database that UNOS uses. Everything about the donor organ was correct, and UNOS correctly matched that organ set to another patient at Duke. When Duke decided to divert those organs away from the patient UNOS had a match for, responsibility for proper patient matching shifted away from UNOS and directly to the Duke surgeons. The UNOS computer match was flawless here, it correctly matched the donor organ set to another patient. However, Duke essentially bypassed this computer match result when it diverted these organs to Jesica, whom DID NOT appear on the match list generated by the UNOS computer for that particular organ set.

 

[VienneseWaltz]

Originally posted by MacGyver
A 2 minute phone call to UNOS would have avoided this whole situation.

A 2-second glance at the paperwork would have avoided the whole thing. I think the point here is that any one of a series of small steps could have avoided the whole thing.

At some point, both New England Organ Bank and Carolina Donor Services were in direct contact with Duke. Duke didn't divert an organ--it asked CDS if it could have the organs for Jesica. Both parties failed to confirm blood type, and Duke failed again when it did not check the blood type before the surgery.

 

[MacGyver]

Originally posted by VienneseWaltz
Duke failed again when it did not check the blood type before the surgery.

Would you at least agree that this was a departure from standard medical care and therefore medical malpractice?

 

[VienneseWaltz]

Originally posted by MacGyver
Would you at least agree that this was a departure from standard medical care and therefore medical malpractice?

Of course--I'm not absolving Duke from guilt in this situation, but there was a mistake on both sides. Earlier reports were that the organs arrived for another patient, but Duke diverted them to Jesica after they were declined for the original recipient. Current reports are that this is NOT the case--CDS approved the organs specifically for Jesica. During the conversation, neither Duke nor CDS verified her blood type, meaning that both parties are at fault. The greater degree of culpability does lie with Duke, in my opinion, because they should have checked again. My point is that no one at CDS has accounted for its actions, so we don't know why CDS didn't ask about her blood type before releasing them to Duke specifically for Jesica.

UNOS and CDS (the Carolina agency) are not the same thing, as someone said earlier. Maybe someone can clear this up, but my understanding is that UNOS provides the match and then the exchange is handled via regional transplant coordinators (in this case, New England Organ Bank, which worked with the donor, and Carolina Donor Services, which worked with Duke).