• Saundra Smyrski

Patient Receives a Kidney Transplant Meant for Someone Else



A missed diagnosis. Delayed diagnosis. Medication error. Infection. Unsafe medical device. I've seen it all. I've consulted on it all. And while an error is an error is an error... every now and then, something still catches me off guard. Something like transplanting a kidney into the wrong patient.


No, I am not kidding. Like you, I wish I was. This is exactly what happened recently, this month actually, at The University Hospitals of Cleveland. "We are dismayed that an error recently occurred resulting in one patient receiving a kidney intended for another," spokesperson George Stamatis told WKYC. "Another patient's transplant surgery has been delayed."


Prior to birthing my Neuro Law Consulting Firm, I was fortunate to be employed at the region’s only center for Level l trauma and comprehensive burn care. Also, being this academic institution is one of the nation’s busiest adult solid organ transplant centers, it was a real honor to call it "home." A once in a lifetime opportunity to stand along my fellow Neuroscience critical care family, as a valued member of this nationally accredited comprehensive stroke center, 82-bed Level IV neonatal intensive care unit, and a state-certified spinal cord and brain injury rehabilitation center <------ My stomping grounds!


Although, a Neuroscience critical care die-hard, I have participated in my share of surgical procedures. All the more reason this caliber of event blows my mind. A "never event" hands down.


The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors—such as wrong-site surgery—that should never occur. Over time, the term's use has expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.


"Never Events" consists of 29 "serious reportable events" grouped into 7 categories:

  • Surgical or procedural events

  • Product or device events

  • Patient protection events

  • Care management events

  • Environmental events

  • Radiologic events

  • Criminal events

You can view the entire list here: https://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx


Most Never Events are very rare. For example, a 2006 study estimated that a typical hospital might experience a case of wrong-site surgery once every 5 to 10 years. However, when Never Events occur, they are devastating to patients–71% of events reported to the Joint Commission over the past 12 years were fatal–and may indicate a fundamental safety problem within an organization (Agency for Healthcare Research and Quality, 2019).


If you believe your client has been a victim of a "Never Event," contact a top-rated experienced medical malpractice focused certified legal nurse consultant today.

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