CLEVELAND — *Editor's Note: The video in the player above is from a previous report.
It's been one week since University Hospitals confirmed that due to an error, a patient received a kidney that was intended for someone else. Officials with the hospital cited the mistake as a " breakdown in following protocol during organ verification."
On Friday, University Hospitals CEO, Cliff Megerian issued a statement to his staff, committing to the safety of patients--" Making zero harm our highest priority."
"The error should never have happened, and it runs counter to the goals for safety and excellence we advocate throughout our health system," said Megerian in the letter.
The mix-up took place on July 2. Fortunately, the patient has been released from the hospital and is recovering well up to this point.
CEO Mergerian in his letter also applauded the quickness and efficacy of University Hospital employees and staff members.
"Our response to this event reveals the character of UH and our people. We promptly notified the patients and families involved about the error and apologized sincerely," said Megerian. "We further pledged to investigate and take actions that strengthen quality and safety for all, which we have done and continue to do."
Moving forward, Megerian says the way to prevent similar mistakes in the future is with " attentiveness to detail and dedication to a culture that puts safety first." He went on to say the all staff members are accountable, regardless of position, to speak up at any sign of risk to the safety and wellbeing of their patients and one another.
Prior to the transplant error, University Hospitals enlisted the help of Dr. Peter Pronovost, renowned leader in health care safety and change management, to assist with the "zero harm" goal. Following the transplant error, the team has achieved the following:
- Established a Zero Harm executive cabinet.
- Reviewed our transplant policies and procedures, which have been modified to increase redundancy in the verification of organs and patients.
- Conducted training with appropriate transplant personnel that reinforces compliance with organ verification protocols.
- Initiated a project to determine the feasibility of incorporating bar code validation in organ verification.
- Expanded evaluation of the incident to include a broader assessment of our transplant program.
- Commenced the engagement of an expert third party to conduct a cultural safety assessment of the transplant program.
"It is important that we honor the trust our patients place in us. I count on every UH caregiver to double down on quality and safety, and to always speak up," said Megerian. " We are on a continuing journey to Zero Harm, because our patients’ lives depend on us."
You can read the full letter from CEO Cliff Megerian below:
All of us at University Hospitals are disappointed and distressed by the error in our transplant program that resulted in a patient receiving the wrong kidney and a transplant delay for a second patient. The incident resulted from a breakdown in following protocol during the organ verification process.
We recognize the pain this situation has caused our patients, their families, and also our caregivers. The error should never have happened, and it runs counter to the goals for safety and excellence we advocate throughout our health system. Thankfully, the patient has been released from our hospital and to this point is recovering well.
Our response to this event reveals the character of UH and our people. We promptly notified the patients and families involved about the error and apologized sincerely. We further pledged to investigate and take actions that strengthen quality and safety for all, which we have done and continue to do.
We also moved swiftly to notify the United Network for Organ Sharing, in its role as a government regulator overseeing transplant medicine, and we are working with the Ohio Department of Health and The Joint Commission. The lessons we learn from this event will be shared system-wide and with other health systems to improve safety everywhere.
We know that errors happen far too often in health care, and the causes are complex. The way we will prevent mistakes is through attentiveness to detail and dedication to a culture that puts safety first. Each of us, regardless of position, is accountable to speak up whenever we see a potential risk to the safety and wellbeing of our patients and each other.
We are fortunate to have Dr. Peter Pronovost, a nationally renowned leader in health care safety and change management, on our team. Even before the transplant event he was leading a campaign to instill Zero Harm as our clinical goal. This work continues.
Among our actions following the transplant event, we have:
- Established a Zero Harm executive cabinet.
- Reviewed our transplant policies and procedures, which have been modified to increase redundancy in the verification of organs and patients.
- Conducted training with appropriate transplant personnel that reinforces compliance with organ verification protocols.
- Initiated a project to determine the feasibility of incorporating bar code validation in organ verification.
- Expanded evaluation of the incident to include a broader assessment of our transplant program.
- Commenced the engagement of an expert third party to conduct a cultural safety assessment of the transplant program.
It is important that we honor the trust our patients place in us. I count on every UH caregiver to double down on quality and safety, and to always speak up. We are on a continuing journey to Zero Harm, because our patients’ lives depend on us.