Patient given wrong kidney transplant

Jan 21 2008

A KIDNEY recipient had to have the new organ removed, hours after the transplant, when it was found the patient’s blood type had been incorrectly recorded.

The mistake was made after staff at the Royal Liverpool and Broadgreen University Hospitals Trust wrongly recorded the patient’s blood type as A positive and sent it to the computerised national transplant database.

The correct blood type, O positive, was reportedly entered clearly on the hospital’s paper records.

The body which manages the database, UK Transplant, then sent out a compatible kidney with an A positive patient, which was transplanted.

The error was picked up when a data clerk at the hospital checked the patient’s notes against the computer record after the operation.

Checks revealed that a second renal patient had been registered with the wrong blood group.

The transplant patient made an "uneventful recovery" and was discharged.

It was not known whether another kidney was found, or if the first transplant kidney came from an anonymous donor or a family member.

The patient came from an area covering Merseyside, North Wales and the Isle of Man, but no further identifying details were known.

The incident, thought to be the first of its kind in Britain, was revealed in a Freedom of Information request by a Sunday newspaper.

A report into the mistake, which happened three years ago, does not name which of the three hospitals managed by the Trust was involved.

The report concluded 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. The report blamed UK Transplant for failing to set up a standard nationwide system for entering patient details.

It reportedly 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."

However, a spokeswoman for UK Transplant said the organisation had no responsibility for the way trusts entered information.

"We need to be clear; the mistake here was not with UK Transplant. 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."

A spokeswoman for Royal Liverpool and Broadgreen University Hospitals Trust said: "This was regrettable. A thorough investigation was concluded in 2006 and a series of improvements have been made since. There have subsequently been no other instances of this happening within our hospitals."

"The improvements ensure fewer people are involved with inputting patient details, that there are more stringent checks and that transplant patient details are validated at all stages."