Entire UPMC transplant team missed hepatitis alert

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The positive hepatitis C test that was missed at UPMC, leading to the shutdown of its living donor kidney transplant program, was not noticed by its entire transplant team despite a highlighted alert in the hospital's electronic records system.

"Everyone just missed it," a source with knowledge of the case said.

The alert was missed by as many as a half dozen people on the transplant team who typically would have reviewed such a test result, according to interviews with several current or former UPMC employees. A number of those interviewed said the problem lies more with the larger system of ensuring that medical errors are caught than with the individuals involved in the incident.

Because of the missed positive test result, a kidney from a living donor, who did not know she was infected with the disease, was transplanted into a man who did not have hepatitis C, leading to two ongoing federal investigations.

It is still not clear if the recipient has contracted the disease, but the medical error led UPMC to demote a surgeon and suspend a nurse two weeks after the error was first discovered May 6.

The surgeon who was demoted is Henkie P. Tan, a nationally recognized expert in the field of laparoscopic nephrectomy, who was stripped of his title as UPMC's director of the living donor transplant program. His title disappeared from his biography on the UPMC website's experts page two weeks ago.

Dr. Tan does virtually all the living donor kidney removals himself. He famously brought the minimally invasive technique to UPMC when he came here in 2002 with Amadeo Marcos, the former UPMC transplant chief who was ousted under scandal in 2008.

The nurse who was suspended for two weeks is Mimi Funovits, a longtime, nationally known certified transplant coordinator who is a board member and past president of the International Transplant Nurses Society, and has been a co-author on transplant research that came from UPMC in the past.

Neither Dr. Tan nor Ms. Funovits, who was the coordinator responsible for all the testing and monitoring of the donor in the weeks and months before the surgery, responded to numerous requests for interviews over the last month.

UPMC officials have been telling living donor patients in recent weeks that they expect to restart the program later this month, after it was shut down voluntarily by the hospital system on May 6.

UPMC discovered then that it had transplanted a kidney from a living donor despite a test that showed she was hepatitis C positive. Had the transplant team recognized the fact that they had a positive test, they would not have gone forward with the transplant into the man, who was not hepatitis C positive. Further complicating the case, the donor, a woman, and the man are a couple.

It's not clear why so many people missed the alert in the electronic medical records systems, which supporters trumpet as a way to specifically help doctors and nurses NOT to miss such a test result.

But some UPMC doctors have complained that the hospital system's acclaimed electronic records system, designed in coordination with Cerner, an electronic records company, is, at best, cumbersome to use and difficult to adjust for any one doctor's particular needs.

It's a problem nationally, say other transplant doctors.

"Electronic medical records can make it difficult to find test results," said Lloyd E. Ratner, a transplant surgeon at Columbia University in New York. "And with some systems, there can be a warning overload, where you get so many of them, you start to ignore them."

The UPMC discovery prompted two federal investigations: one by the Centers for Medicaid and Medicare Services, and the other by the United Network for Organ Sharing, which oversees transplant centers for the federal government. Both agencies have completed their on-site investigations but not yet reported their final findings.

UPMC's calls to patients about the possible restart of the program are apparently being prompted by the fact that UNOS's Membership and Professional Standards Committee is meeting Monday in Chicago.

The committee may consider approving the restart of UPMC's living donor kidney and liver programs. The liver program was shut down two days after the kidney program because the transplant coordinators at UPMC who work with donors before surgery are the same.

Spokeswoman Gloria Kreps said UPMC would not comment for this story, except to say: "In response to patient inquiries, we have expressed our hope that our live donor kidney and liver programs will soon be reactivated. We remain committed to frequent, open communications with and the ongoing care of the patients who have entrusted their care to our transplant team." She would not say who now oversees the living donor transplant program.

In the wake of UPMC's disciplinary action in the case, members of the patient community and people who have worked with Ms. Funovits expressed shock that she was targeted in the investigation.

"She's a really thorough nurse," said a former UPMC coordinator. "I'd let her take care of me in a heartbeat."

People had more disparate views of Dr. Tan.

Some praised his skill and abilities, but others noted that all the pressure he was under in recent years seemed to have taken a toll.

"He's very well regarded in the field," said Dr. Ratner, the transplant surgeon who did the nation's first laparoscopic nephrectomy and transplant in 1995 at Johns Hopkins University, and who taught Dr. Tan the skill. "He's known to be an outstanding technical surgeon and a good doctor."

But former UPMC colleagues say in the years since Dr. Marcos left and the number of kidney transplants fell precipitously, Dr. Tan felt pressure in recent years to do more transplants. Pressure also came from the fallout from a bitter, nearly three-yearlong divorce that ended only last fall.

"It all clearly compromised the optimization of his clinical practice," said a former colleague of Dr. Tan's. "This kind of error is the kind of thing that happens when you're always pushed for more volume."

Even so, some transplant chiefs at other hospitals questioned why either Dr. Tan or Ms. Funovits were targeted in this case.

"These problems arise from a systemic problem," said John Fung, head of transplant surgery at Cleveland Clinic, the same job he held at UPMC until 2004. "You should never have to rely on any one person."

Besides, he said, "if everyone in transplants got hit for making a mistake, no one would be working."

Dr. Ratner agreed: "The sort of knee-jerk reaction from an administrator is to, you know, make heads roll, regardless of the fact that Dr. Tan is an outstanding surgeon and well-regarded in the field."

He then quoted from a section of the landmark 1999 report "To Err Is Human" from the U.S. Institute of Medicine that brought attention to medical errors: "The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system."

Sean D. Hamill: shamill@post-gazette.com or 412-263-2579.


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