On January 29, 2011, in Los Angeles, two kidneys arrived at the University of Southern California University Hospital, ready for transplant into two patients who desperately needed them.
On February 18, 2011, the Los Angeles Times reported that one of those patients had received the wrong kidney.
In that same story by Alan Zarembo and Lisa Girion of the Los Angeles Times, the USC University Hospital declined to comment on the nature of the mistake, chalking it up as a "process error" they discovered after the transplant had occurred. The program that ran the transplant services outlined that the packaging and documentation were correct, and that the error was ”presumably” human.
Luckily, the patient escaped harm, as the kidney that was used for the kidney transplant was from a donor whose blood type was O (the universal blood type). We say luckily, because using the wrong organ in a transplant can be deadly; especially if it is something as important as a kidney, and if the mistake isn't caught right away.
The USC Hospital decided internally to shut down their kidney transplant unit as a result of the mix-up.
How did something like this happen? How did a patient receive the wrong kidney?
Back in 2011, the USC Hospital declined to comment on the nature of the mistake, so we don’t know. But, in the report by the Los Angeles Times, they did say it was a ”human error,” and that it was not the fault of their packaging and documentation.
A hospital supply chain is an interesting beast to tackle, because it is so diverse and yet so important. Materials that move into a hospital range from bed pans to needles to blood and kidneys, so an accurate supply chain is essential to differentiate goods that are moving in and out of the hospitals bay doors. Accurate to the extreme. Accurate to an exceptional degree. Accurate where mistakes like the one the USC Hospital made don’t happen.
Breakdowns in the supply chain for hospitals are the result of this diversity and the expanding nature of the hospital supply chain in general. Hospitals are being asked to do more than ever, and that means their supply chains are expanding to new markets. As we detailed in last month’s catalog, in a post titled, "The Ever Expanding Supply Chain" with the change from a quantity versus quality model for reimbursements in healthcare due to the Affordable Care Act, hospitals are looking to cut out middle-man distributors, and buy directly from medical device manufacturers. This obviously doesn't have to do much with a misplaced kidney, but the theme runs through both practices: with an expanding supply chain, and a diverse supply chain, a hospital’s accuracy will be tested.
We've also discussed in previous issues of Insights the effect of serialization on a supply chain’s accuracy, and how lost, damaged, and stolen goods can be limited with the effective implementation or update of a serialization system. However, in the case of USC, it seems that the supply chain didn't fail, we humans did.
But, humans are a part of the supply chain, and for the foreseeable future, they will continue to be a part of it. Human mistakes can be accounted for in the supply chain, with increased automation and more checks and balances, but they will probably always remain. The goal of a supply chain is to limit both process mistakes and human mistakes, to the highest possible degree.
When supply chain screw-ups happen in a hospital, the result is a harmed patient. That’s the title of this article, and it couldn't be more true when discussing the example used above, taken from a report by the Los Angeles Times reporters Zarembo and Girion. That’s an extreme example, and luckily, the patient who was operated on wasn't harmed. One, hospitals and patients aren't always so lucky. And two, sometimes mistakes aren't so apparent and disastrous, more subtle and quietly harming a hospital’s patients.
Take our bed pan reference from above. If a bed pan order gets misplaced, shipped to the wrong address, or goes missing for some odd reason, it may not seem like the end of the world. But, that effect will be felt by a hospital’s staff and thus a hospital’s patients. Less bed pans may mean that the current bed pans have to be used more often, and thus washed and sanitized more often. That asks the cleaning crew to wash more in the same amount time, it asks the nurses to change bed pans out more frequently, and it may end up meaning a patient doesn't receive a bed pan, or worse, his/her quality of care is lessened because so much focus is being paid to bed pans. This all the result of one small mistake in the supply chain.
The repercussions of a supply chain breakdown are far reaching: they hurt more than just the purchasing department.
In our research over the past year, we've found that supply chains can be ruined through the mishandling of products in an enormous variety of ways, from mislabeling to hi-jacked goods to a leak in a semi-truck’s roof.
For hospitals, it’s imperative that these mistakes don’t happen, as they result in the worst.