After the wrong patient received a kidney transplant, USC University Hospital in Los Angeles halted its kidney transplant program on Jan. 29, the Los Angeles Times reports.
Luckily, the "never event" did not harm the patient, because the organ by chance was a suitable match. The person who was supposed to get the misplaced kidney received one a few days later.
Although the hospital confirmed the temporary stop to transplants, saying a process error was found, it did not explain what happened. Two kidneys from separate donors arrived on a Saturday at about the same time, the Times reports.
"I can't even imagine how this mistake could have happened," Dr. Goran Klintmalm, a surgeon at Baylor Regional Transplant Institute in Dallas, told the newspaper.
The incident has triggered probes by the state health department and the United Network for Organ Sharing, which monitors the transplant system for the U.S. government. The hospital deactivated the transplant program to assess clinical protocols and develop more safeguards, the Times reports.
The long-term fallout will likely be much lighter than what happened to Kaiser Permanente in 2006. After multiple serious deficiencies came to light, including 90 dead patients on Kaiser's waiting list, the program was forced to close.
USC University Hospital officials have said that the transplant program could resume today.
To learn more:
- read the Los Angeles Times article