Doctor, nurse disciplined by UPMC in kidney transplant case

Failed to detect hepatitis C in kidney donated for transplant

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A surgeon and a nurse were disciplined by UPMC for their roles in missing a positive hepatitis C test result in a kidney donor earlier this month that might have stopped the transplant, the hospital system said Thursday.

The surgeon was demoted and the nurse suspended, though neither has been identified.

In addition, after a discussion with federal officials, the hospital system voluntarily suspended its live-donor liver program as a precaution, three days after shutting down its live-donor kidney program on May 6, following the transplant error. Both programs remain closed.

But while UPMC has taken action against the two staff members, health care technology experts say UPMC's information technology might have played a role in the incident.

"Checking for all types of hepatitis is so ingrained in the culture of doctors," said Scot Silverstein, a medical informatics expert and adjunct professor at Drexel University in Philadelphia. "If they didn't check for hepatitis C, that means they didn't check for hepatitis A or B either, and that means they didn't check for anything."

"That just isn't credible," said Dr. Silverstein, who explored the possible ways the technology played a role in the kidney transplant error in the blog Health Care Renewal.

"There are two possibilities," he said. "Either you have a dozen or more people on that transplant team who are just stupid, or, more plausibly, when they looked at the record the hepatitis C record was just not there or it was incorrect when they saw it."

The incident first came to light May 6, when UPMC notified the Centers for Medicare and Medicaid (CMS) as well as the United Network for Organ Sharing, that it had detected an error in a recent kidney transplant..

It was a living kidney transplant between a woman and a man who are a couple, sources have told the Post-Gazette. The woman did not know she was hepatitis C positive, and she was tested, but the test results were somehow missed by people on the transplant team, and the transplant went forward.

On May 11, Elizabeth Concordia, UPMC's executive vice president, briefed board members of the hospital system on the incident.

She told them, according to one board member, that the positive test result for hepatitis C was missed by two people on the transplant team during a dozen steps in the process. She called that a "systemic" problem in the way the protocols failed in that one case, the board member said.

Because of the error, UPMC had decided on its own on May 6 to shut down the living donor kidney program.

Then, on May 9, when UPMC officials were discussing the situation with the U.S. Health Resources and Services Administration, they mutually decided to shut down the living donor liver program, too, said Michele Walton, a CMS spokeswoman.

"They found out that the same people do evaluations of the patients in the kidney program also do the evaluations in the liver program and it made sense to shut them both down," Ms. Walton said.

UPMC spokeswoman Jennifer Yates said shutting down the liver program was not because of any issues with the program.

Ms. Yates on Thursday refused to divulge any details about the identity of the surgeon or nurse. She would not characterize the demotion or release specifics of the suspension. It is not clear whether the surgeon and the nurse were part of the team operating on the kidney donor or the recipient.

"It's a personnel issue, and I really can't say anything more than that," she said.

Revelation of the error in the transplant was the impetus for federal, state and county investigations into the incident, none of which are complete.

UPMC had hoped to restart the programs in June, but Ms. Walton said the joint CMS and Pennsylvania Department of Health investigation has not even begun.

She said the investigation would include reviews of both the liver and kidney programs that would take one or two days each.

But if the hospital's electronic health record played any role in the error with the kidney transplant, it could greatly expand the investigation, Ms. Walton said.

Instead of just a transplant center investigation, it would grow into a hospital investigation that would take three or four days to complete by itself, she said.

Dr. Silverstein and other experts say the current electronic health records systems that highly wired hospitals like UPMC have in place routinely flag test results for everyone connected to a surgery to see.

But those systems have been known to cause the same kinds of errors they were designed to prevent over the old-fashioned paper records.

A 2010 Huffington Post Investigative Fund report found that the Food and Drug Administration, which gathers information about health information technology, had recorded 237 "adverse events" that included accounts of six deaths and 43 injuries to patients because of problem with the electronic records.

Ms. Yates said she could not discuss what if any role the hospitals' health information technology system played in the error.

A spokeswoman for Cerner Corp., which provides the technology for UPMC's in-patient electronic health record, did not return a call seeking comment.

But experts say that systems similar to UPMC's typically flag test results this way:

When a result comes in, an alert is made either by highlighting the result on the computer record, or even sending text or email alerts to doctors and nurses who need to know about it, experts said.

Some systems will prevent a nurse or doctor from going forward to the next screen until they acknowledge that they saw and understood the test result, kind of like bill-paying websites make users check a box on a consent form before it will accept a payment online.

"It does puzzle me about how a hepatitis C result would be missed," said Richard Schaefer, chief information officer at St. Clair Hospital in Mt. Lebanon. "If there was a positive test result like that, I would think the results would be flagged and brought to someone's attention."

"Alert fatigue," in which so many alerts flash that nurses or doctors tend to ignore them, is a real possibility, said Mr. Schaefer.

As a result, his hospital created a committee to review whether any new alerts need to be coded into their system for a specific procedure.

"We decide if a test or a result is worthy of firing an alert, and decide if we want to make our doctors make another click," he said.


Jonathan D. Silver: jsilver@post-gazette.com or 412-263-1962. Sean D. Hamill: shamill@post-gazette.com or 412-263-2579.


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