The investigation of how a child in Boston received Hepatitis C via cardiac surgery in which blood vessel tissue was transplanted, revealed a case of human error in reading the hepatitis status of the donor back in March.
Human error WILL occur and resilience in catching and responding to these errors is what will keep patients safe. Resiliency is the ability of a system to adjust its functioning in the event of a mishap or under a state of continuous stress (Nemeth, Wares, Woods, Honagell & Cook, 2008). Even after the error in reading the tissue occurred there was opportunity to prevent the error from reaching the child. Another person who had received a kidney from the same donor tested positive for Hepatitis C but it was 11 days before a communication occurred with the Office of Blood, Organ, and Other Tissue Safety at the CDC (Conaboy, 2011, Boston Globe). The child’s surgery was performed 3 days before the official communication but 8 days after the kidney recipient tested positive. As soon as the first kidney recipient tested positive, the human error should have been discovered and further infections could have been prevented. A human error occurred but system problems and communication impairments made this a larger catastrophe than it should have been. This illustrates that while the sharp end workers are prone to human errors, the blunt end administrators can add resiliency by looking to build safer processes and systems. Compounding this error was the fact that organs and tissues are regulated by separate agencies. Tissue banks are overseen by the FDA and Organs by the Health Resources and Services Administration (Conaboy, 2011). The two have no protocols for sharing information. This is eerily similar to the situation prior to the 911 attacks in that the FBI and the CIA had no protocols for sharing information.
This is a lesson for all in terms of the open sharing of data. We must break down silos in healthcare where they occur and increase opportunity for feedback to those in the system as to the functioning of the system whenever possible. Putting the patient at the center of all we do is a first step in identifying how and where these silos exist. Human error will occur but monitoring the system and sharing information will create resiliency that will mitigate harm.
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