January 25, 2008 | Mark Paradies

UK National Health System Admits Error – Patient Given Kidney of Wrong Blood Type – Root Cause: “Human Error”

A story in The Mail on Sunday, a UK paper said:

Elizabeth Ward, of the British Kidney Patients Association, said: “I’m quite sure it’s the first time this has happened in this country. It’s hard to understand how this could have happened.”
What was she talking about? A kidney transplant patient was forced to have the new organ removed after just a few hours – when it was discovered that the patient’s blood type had been incorrectly recorded on a computer database.

The incident, which was only revealed in response to a Freedom of Information request, comes just days after Gordon Brown called for a system in which individuals are presumed to consent to the use of their organs for transplant unless they specifically stipulate otherwise.

The error took place three years ago and would have remained secret had The Mail on Sunday not seen a confidential report into the “profound error”.

The internal investigation did not name the hospital involved. The report concluded that the initial data entry mistake was “human error” but said “there was no means of identifying” who did it, or where the incorrect information had been entered.

Although the mistake was made by Hospital Trust staff, the report blamed UK Transplant for failing to set up a standard nationwide system for entering patient details. It said: “During this investigation it became apparent that any number of professionals could have entered the blood results on to the computer.

“UK Transplant do not have a uniform system in place. [They] have not been prescriptive in dictating practice, and have allowed local Trusts the freedom to adopt whatever systems they deem fit.”

But a spokeswoman for UK Transplant said the report was “misleading” as the organization had no responsibility for the way Trusts entered information. “We need to be clear that the mistake here was not with UK Transplant,” she said.

“Information that Trusts provide is what goes into the national database. In this case, we have correctly recorded incorrect data. Our system has been in place for several years and can be viewed by Trusts at any time to check the data we’re holding.”

Once again, BLAME (rather than a fix for the problem) seems to be a major issue.

A source at UK Transplant said the mistake was “extremely rare” as fewer than five of the 20,000 organ transplants in the past seven years were made in error.

Hmmm … 5 in the past seven years? That sounds like more than “This has never happened before.” And if the reports aren’t made public, how can this error rate be verified?

For the complete article, see:


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