More Problems at Hershey Transplant Program

By Walter F. Roche Jr.

A living donor kidney transplant procedure at the Milton Hershey Medical Center had to be halted after the donor had already been anesthesized, according to a a six-page report from the state Health Department.
The new report was made public just days after another state report detailed errors that led to the shutdown of the abdominal transplant program.
In a report made public last week, state inspectors found multiple cases in which the recipients of the transplanted organ were not told before surgery that the organ they were about to receive had been classified as high risk for failure.
In the newly released report state surveyors found that the living donor had already been put under general ansthesia when it was discovered that test results on the recipient showed that it might be "inadvisable" to go forward with the procedure.
"At that time I learned that there could be issues with the recipient, and we might not be able to proceed," an unidentified member of the transplant team told the surveyors.
"The living donor was put under anesthesia due to miscommunication regarding labs of the recipient," the report states.
The procedure was then halted and the patient was taken to the recovery room, according to the report. The incident occurred in March just weeks before the program was suspended.
When the health inspectors asked if there was a written policy in place to ensure coordination, they were told there was no written policy.
The facility filed a plan of correction calling for better communication between members of the transplant team including audits to ensure 100 per cent compliance.
The new process, the report states, will ensure "that the living donor is not subject to unnecessary procedures, medication or risks."
The report does not indicate whether the transplant was performed at a later date.
Hershey officials told the state that the confusion over the test results came after a change was made in the scheduling procedure. Under the old procedure tests were performed the day before the transplant. The new procedure called for the tests to be performed the same day as the transplant.
The report also cited the failure to fill out required forms.
Also contributing to the confusion was the fact that some members of the team were new.
In the report issued last week state inspectors found that the consent process was not being properly executed.
They also cited the fact that many Hershey tranplant patients had to be returned to the operating room due to the misplacement of the donated organ and, in one case, a perforated colon.
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