The behemoth healthcare system, University of Pittsburgh Medical Center, had its living donor transplant program temporarily shut down after a patient was transplanted with a kidney from a hepatitis C infected donor. The details of the fateful transplant can be found in two well-written articles in the Pittsburgh Post-Gazette (
here and
here). It's a classic example of the swiss cheese model of complex system failure, where all the holes lined up (in this case the positive lab test was missed on 6 occasions), allowing an adverse outcome to occur. The articles note that UPMC's response was to demote the transplant surgeon and suspend the transplant nurse coordinator. A noted transplant surgeon describes that as an administrator's knee jerk reaction and another stated,
"if everyone in transplants got hit for making a mistake, no one would be working." But the journalist probes to unearth how the system fostered the error, and he notes the stresses on the surgeon to increase surgical volume (as well as stressors in his personal life), problems with the electronic medical record, and alarm fatigue.
I have been intrigued at how physicians who perform the most highly technical procedures in medicine can sometimes be uninterested in details that ultimately can unravel their programs. What infectious diseases physician hasn't been consulted to see a patient who has undergone an amazingly complex surgical procedure, who survived against all odds only due to an enormously talented surgeon, all to be undone by sloppy infection control practices down the line, such as noncompliance with hand hygiene? In the UPMC case, I have to wonder whether a simple tool, such as a checklist, could have prevented this error.
