Friday, May 27, 2011

Person or system problem, or both?

I am going to do something really wrong, commenting without knowing all the facts. But guessing from a press report, I am betting that this story is not totally a person problem:

A Pennsylvania medical center demoted a surgeon and suspended a nurse who were involved in the transplant of a kidney from a donor who had hepatitis C, a spokeswoman said on Thursday. The University of Pittsburgh Medical Center has also suspended its live-donor liver program as a precaution, though no problems were found with that program, UPMC spokeswoman Jennifer Yates said in a statement. The medical center voluntarily suspended its live-donor kidney transplant program earlier this month after discovering the infected kidney and notified the United Network for Organ Sharing, a national transplant agency. The agency plans to conduct a review.

It will be interesting to follow this story as it develops. It will also be revealing to see if UPMC shares the results of what they learn more broadly with the transplantation community.

In the meantime, will this have an impact on the hospital's ad campaigns?


Juliana said...

From Facebook:

The action to remedy the situation was a bit severe, or to save face they did that knowing their DPH would be heavily investigating the situation.

I could be wrong, too.

Anonymous said...

By reputation at least, the UPMC transplant program is one of the older and presumably more knowledgable ones. However, this situation produces an interesting dilemma for them in terms of public relations. If somehow the surgeon and nurse willfully violated protocol, such as by deciding to proceed before proper testing was done, for instance, then they deserved to be disciplined - but who wants it to be known there are rogue players in your transplant program, and why suspend your program if it's a clear-cut case of violation? If, otoh, there was no willful violation but some error, then why discipline selected participants while you are suspending your program to review protocols?

I am probably oversimplifying the case a bit here, but it's clear that transparency is the best policy in all cases, to prevent just this sort of speculation and mistrust.

nonlocal MD

Guzzo said...

Mistakes are almost always a systems problem. A system of written checks, and double-checks, probably would have avoided this very unfortunate error.

jonmcrawford said...

Isn't this exactly what we were all saying needed to happen, a la Blue Angels? This article was pretty vague, I'll have to dig around more for real info, but this seems to be the right step, identify a problem, suspend operations until the problem is resolved.

Anonymous said...

Jon, my problem was that they suspended operations simultaneously (I suppose) with firing the 'culprits'. The true systems evaluation would have been, suspend operations, investigate the issue quickly but thoroughly, determine using 'just culture' principles whether there was a willful violation of policy, and only finally, if merited, fire people. Instead, this smacks of jumping to conclusions and suspending operations merely for show.
But we won't know, will we, since they are not being transparent about it? Doesn't that leave a question in your mind if your loved one needed a transplant?

nonlocal MD