Failed processes in collecting, screening and transplanting donated organs in the US are responsible for at least 70 deaths and the development of 249 preventable diseases, the Senate Finance Committee revealed in a report Wednesday.
The full report, which was obtained by the Washington Postcites failure to identify diseases in organs that would cause problems for the next host, mismatch of blood groups and perfectly usable organs that are lost or discarded due to mismanagement in the transport chain.
These cases included a South Carolina man who received transplanted lungs that were incompatible with his body — killing him the next day. A heart transplant patient in Wisconsin was told they would die within three years after it was discovered that the heart they had just received came from a person with brain cancer.
The error for these issues is spread across multiple groups. First, the individual non-profit organizations that arrange the procurement and transplantation of organs in each region, called organ procurement organizations (OPOs). The United Network for Organ Sharing (UNOS) is also responsible for overseeing those groups. Then, of course, federal officials are also responsible for regulating these groups.
According to official data, there are currently 105,960 Americans on the transplant list, with 17 dying every day while waiting. A new person is added to the list every nine minutes.
At least 70 deaths and the development of 249 diseases between 2008 and 2015 can be attributed to poor screening and other mismanagement of organs by contractors charged with their management (file photo)
The report submitted by the commission included 1,118 reports submitted to UNOS between 2010 and 2020. The 70 death toll included data from 2008 to 2015.
During the seven-year period in which the deaths occurred, 174,338 organs were transplanted in the United States.
While significant errors were rare, they could be devastating if they did occur.
The documents list multiple organs that could have been used instead and were inexplicably discarded or lost.
In 2020, two healthy kidneys were accidentally discarded in Indiana. About one in five kidneys purchased for transplant was not used that year, with no concrete explanation as to why in most cases.
In 2015, a donated kidney was lost while traveling by air from South Carolina to Florida. Another was lost in 2017 when it was shipped from Palmetto State to California.
In both cases, a transplant recipient’s surgery was canceled as a result of the error.
Sometimes an organ that had already been transplanted had to be removed from the recipient after doctors found out there was a problem that could cause serious complications.
UNOS leaders said they are “committed to continuous improvement, monitoring and adaptation; one where thousands of people across the country come together every day to save lives. Pictured: UNOS headquarters in Richmond, Virginia
Problems like this should be noticed well in advance of the transplant, with the organ being assessed for blood type and the potential risk of the person receiving it developing a dangerous disease.
Some patients will die as a result. Others will have to undergo multiple surgeries to undo the mistake sooner
A Wisconsin man was told by a surgeon in 2020 that he probably had less than three years to live after receiving a new heart from a person with aggressive brain cancer.
People with metastatic cancer should not have their organs used because there is a risk that the cancer will recur while they are in the recipient.
No information is available about the current condition of the heart receiver.
In 2018, a donor from South Carolina had organs harvested for use in four recipients.
In one case, a man in South Carolina died a day after receiving lungs that were not suitable for transplantation (file photo)
However, there was a mix-up in their blood type, which left all four patients with incompatible organs.
The man who received the donor lungs died the day after he got them.
In 2017, a kidney transplant recipient in Nevada died of tularemia, or the rabbit flu, after receiving an organ from an infected patient.
Another California patient also received a kidney from the same person and was also infected. That patient survived.
‘Ours is a complex system; one that is committed to continuous improvement, monitoring and adaptation; one where thousands of people across the country come together every day to save lives,” UNOS chief executive Brian Schepard said in his testimony to the Senate committee.
“It’s a systems conference that started nearly 40 years ago and that, thanks to the decisions and expertise of those who laid the groundwork, empowers us to best serve patients in need of a transplant.”
However, there is little regulatory oversight of these operations. UNOS is a private contractor employed by the government.
It then hands out the work to the OPOs, who operate in each individual region without competition.
The process is opaque and without proper supervision it is easy to make mistakes – and for groups to blame elsewhere if problems are noticed.