“Last May, the University of Pittsburgh Medical Center shut down its living donor kidney transplant program because of a serious medical error. A man in need of a transplant was given a kidney from a donor who did not know she had tested positive for hepatitis C. The positive test was, however, included in the donor’s medical record, and an automated alert saying as much was missed by all six members of the team reviewing the procedure. The incident resulted in the immediate shutdown of transplants, the demotion of the department head, the suspension of a nurse, and the initiation of two federal investigations.”
Article
Rick McMullen, Fast Company, 17 August 2011
