University Hospitals patient continues recovery after receiving kidney meant for another

CLEVELAND, Ohio (WOIO) - University Hospitals CEO Cliff Megerian issued a statement today regarding the incident where a patient received a kidney meant for another.

University Hospitals apologizes after patient receives kidney meant for another

The incident resulted from a breakdown in following protocol during the organ verification process, according to the statement.

The patient received a compatible kidney and has been released from the hospital.

The patient continues to recover well, according to the statement.

University Hospitals notified the United Network for Organ Sharing shortly after the incident and is working with the Ohio Department of Health and The Joint Commission.

Listed below are the actions taken by University Hospitals after the incident, according to the statement:

· Established a Zero Harm executive cabinet.

· Reviewed our transplant policies and procedures, which have been modified to increase redundancy in the verification of organs and patients.

· Conducted training with appropriate transplant personnel that reinforces compliance with organ verification protocols.

· Initiated a project to determine the feasibility of incorporating bar code validation in organ verification.

· Expanded evaluation of the incident to include a broader assessment of our transplant program.

· Commenced the engagement of an expert third party to conduct a cultural safety assessment of the transplant program.

You can read the full statement from CEO Cliff Megerian below:

All of us at University Hospitals are disappointed and distressed by the error in our transplant program that resulted in a patient receiving the wrong kidney and a transplant delay for a second patient. The incident resulted from a breakdown in following protocol during the organ verification process.

We recognize the pain this situation has caused our patients, their families, and also our caregivers. The error should never have happened, and it runs counter to the goals for safety and excellence we advocate throughout our health system. Thankfully, the patient has been released from our hospital and to this point is recovering well.

Our response to this event reveals the character of UH and our people. We promptly notified the patients and families involved about the error and apologized sincerely. We further pledged to investigate and take actions that strengthen quality and safety for all, which we have done and continue to do.

We also moved swiftly to notify the United Network for Organ Sharing, in its role as a government regulator overseeing transplant medicine, and we are working with the Ohio Department of Health and The Joint Commission. The lessons we learn from this event will be shared system-wide and with other health systems to improve safety everywhere.

We know that errors happen far too often in health care, and the causes are complex. The way we will prevent mistakes is through attentiveness to detail and dedication to a culture that puts safety first. Each of us, regardless of position, is accountable to speak up whenever we see a potential risk to the safety and wellbeing of our patients and each other.

We are fortunate to have Dr. Peter Pronovost, a nationally renowned leader in health care safety and change management, on our team. Even before the transplant event he was leading a campaign to instill Zero Harm as our clinical goal. This work continues.