DC Medical Malpractice & Patient Safety Blog

Cancer of the trachea--or windpipe--is extremely rare, representing only 1% of all cancers. One patient, who had been diagnosed in 2008, had undergone chemotherapy, radiation and surgery, but his tumors were threatening to block his windpipe when technology came to the rescue last month.

The first-ever synthetic windpipe was transplanted on June 9, and last week the patient left the hospital. Created in a lab without using donor tissue, the new trachea was made only of synthetic material and the patient's own stem cells. The process took fewer than two weeks, versus waiting months for an organ donor, CNN reported.

In addition to bringing this patient back from the brink, the landmark procedure means he won't require immune-suppressing drugs, which have significant side effects and can render subjects vulnerable to infection.

After transplanting a kidney into the wrong patient, the University of Southern California University Hospital has shut down its kidney transplant program pending an investigation.

While this may be a unique event at USC, mixups in transplants unfortunately pop up around the country on a regular basis, because of the lack of rigorous safeguards to check and double-check to avoid tragedies. In this case, luck prevailed.

The patient escaped harm apparently because the mistake involved a kidney that happened to have universal blood type “O,” making it a close enough match to avoid harming its unintended recipient.

Kidney transplants are often performed on short notice and outside of normal hours, and the number of people involved -- surgeons, anesthesiologists, nurses, transporters and patients (donor and recipient) -- make them a challenge to coordinate.

Although safeguards are in place to prevent such occurrences, there is never a direct one-on-one relationship between any two individuals involved, which means miscommunications remain possible. Ultimately, the surgeon is responsible for making sure that the patient who's now in the operating room is indeed a patient on this list and is the patient that they wanted to be calling in from this list.

After the hospital realized its mistake, the organ procurement organization performed a cross-match test using blood samples they already had to determine the transplant's compatibility. The hospital then began looking for a suitable recipient for the other kidney, which was later transplanted at a local hospital. The intended recipient of the misplaced kidney received another organ a few days later.

The mixup reportedly occurred after two kidneys from separate donors arrived at the transplant center simultaneously on Saturday, Jan. 29. According to an official with the One Legacy kidney transplant program, the kidney’s packaging and documentation was accurate, suggesting the mistake was the result of human error.

In a statement, the hospital confirmed that it had temporarily and voluntarily halted transplants and said no patients were harmed as a result of the mistake. But it did not provide any details as to the nature of the error and declined to answer questions. The state Department of Public Health is investigating the incident.

“The hospital inactivated the program while clinical protocols are assessed and additional safeguards to the kidney transplant program are developed," the hospital said in statement. The hospital also notified United Network for Organ Sharing (UNOS), a federal program that organizes the distribution of organs for transplant, that the kidney program had been halted. As of Feb. 11, USC had 508 patients waiting for kidneys, including 313 men and 195 women, according to UNOS.

Source: ABC News

The American Red Cross collects and gives out about 43 percent of the blood given to medical patients in this country, which is why it may be unnerving to learn that the organization has not been following federal quality-control standards.

From the article:

The F.D.A. found shortcomings in the way the Red Cross screens donors for possible exposure to infectious diseases, failures to swab arms properly before inserting needles, failures to test for syphilis and failures to discard potentially risky blood, among other deficiencies.

There is no evidence of actual harm resulting from the Red Cross's failure to abide by federal standards. However, the reason for this lack of evidence is partly because Red Cross has failed to investigate potential harm. If nobody looks for evidence of harm, then naturally it will not be found.

Again, from the article (which should be read in its entirety):

All told, the Red Cross failed to investigate more than 130 cases of suspected post-transfusion hepatitis between 2000 and mid-2002.

Often the problem is bureaucratic. Just this week, the F.D.A. chided the Red Cross for distributing more than 200 blood products that the organization itself had identified as problematic but failed to intercept before distribution. Other times the failure is deliberate. A blood facility in Philadelphia, with approval from a senior national executive, decided not to recall some 600 units of blood that had been collected using improper methods.

What can a patient do to limit the possibility of receiving improper blood? Very little. In an emergency situation, there may not be any time to inquire closely into the origins of a blood donation. However, the Red Cross is taking steps to ameliorate its problems by re-vamping its blood donation services and creating a centralized database to track the blood.