the State board of health is devastating in its judgment of the King. They think communication failure is the reason why a man was lying down one day without the heart.
It was in the autumn of 2015 that a serious hjertesyk man in the 50′s was told that it was found a donorhjerte to him.
It could have meant a new life for man, ended tragically. Only after that man’s heart was operated out, discovered the doctors in the operating room that donorhjertet was given to another patient.
He was lying in about one day without a heart, kept alive by a heart and life support machines. A few weeks after the operation he was dead of complications.
He left his partner and two children.
the Incident happened at the national hospital, the only hospital in Norway that perform organ transplants. Now the State board of health investigated the incident.
do you Have tips in the matter? Contact Jenny-Linn Lohne and Silje Løvstad mari thjømøe
More would have donorhjertet
It all began: at the same time as the doctors at the national hospital received a message that it was found a free donorhjerte, had another hospital in Scandinavia, sent out a so-called “urgent call”message.
This message provides the patient take precedence on the available donorhjerter on the scandinavian samarbeidssykehusene, because the condition of the person is critical.
Doctors at the scandinavian hospital that had sent out the message, made it clear that they were interested in donorhjertet, but would examine it to ensure that it was appropriate with the patient.
This was according to the report communicated to the transplantasjonskoordinatoren and surgeon at the national hospital.
In spite of the “urgent call”-the message from the other hospital, sent the King his own donorteam for, among other things, to retrieve the lungs.
the Hope was that the other hospital needs for the heart should be waived in time to be able to get the heart.
But the scandinavian hospital accepted donorhjertet. This perceived transplantasjonskoordinatoren, and interpreted it to the point where this was also communicated to the surgeon at the national hospital.
But the message didn’t forward. In the meantime, lay the man in 50-years at the national hospital, waiting for the heart that would give him a new life.
Her partner to the deceased: – I have not lost confidence in the system
Talking past each other
In the same time period called the surgeon at the national hospital donorteamet. In the course of the conversation, it was not perceived that they talked past each other regarding what bodies they had back with them.
This communication was not documented in any way.
It was after this phone call that the surgeon at the national hospital decided to take the hjertesyke the man into the operating room. He believed still that donorhjertet was on his way to the King.
During the initial part of the operation, stopped the heart of the man two times. The surgeon therefore decided to take out man’s heart, even if donorhjertet had not come to the King.
This conflicts with the general rule, which is that the sick heart is not to be taken out before donorhjertet is in place in the operating room. It is done, however, exceptions when the health of the patient warrants it.
In the meantime, the man was connected on the heart and life support machines to be kept alive.
Physician about donorsvikten: – Has never happened before.
First discovered in the operating room
That the heart not was with to the man in the 50′s, was not discovered until the donortemaet arrived in the operating room at the national hospital.
Then it was no longer possible to operate into man’s ancient heart. It had therefore sent out a new “urgent call”, this time for the man who had operated out of the heart with a defect.
A new donorhjertet came the day after, but after complications dead man a few weeks later.
the State board of health has not assessed whether it is the sequence of events that led to the man died, but the physician Arnt E. Fiane, as the leader hjertekirurgisk department at Oslo university hospital in norway, believed last year that it was probably a connection.
HERE IT WENT WRONG: Physician Arnt E. Fiane draws and explains where and what went wrong when a patient was operated out the heart without a new donorhjerte was in place.
Photo: Frode Hansen, VG
– We can assume that the patient got a prognosetap in the course of the day that he was connected to the heart and life support machines, but there must therefore be Helsetilsynet determine, said Fiane at the time.
Fiane also believed that the man had probably survived if not kommunikasjonssvikten between teams had occurred.
Communication failed
In the report points out Helsetilsynet several things that failed:
• Very little communication between the different parties is the written documented. Helsetilsynet has largely been based on oral gjenfortellinger, and the information has been conflicting.
• the Report points out that transplantasjonskoordinatoren was new in the role, as the surgeon had many years of experience, and that this may have affected how they communicated.
• In connection with the hjertesyke the man was prepared for transplantasjonen, did not ask the surgeon what the final answer to the scandinavian hospital with “urgent call” was. But transplantasjonskoordinatoren gave never some explicit information about that it was just the lungs that were sent to the Rikshospitalet university hospital.
• No one else in the team questioned the process. The teams took no responsibility to ensure a proper communication, considered in the report as a risk factor.
– Transplants are a complicated business. When communication fails, it is serious and can have serious consequences so it got here, ” says the acting director of the State board of health, Heidi Merete Rudi, VG.
• It can not be documented that it was used the checklist “Safe surgery” as the ministry of Health introduced in 2010.
the King: – They acted in good faith
Even if Helsetilsynet believe that the King failed in a number of areas in this case, is it not decided to create individual supervision with some of the people involved.
– Helsetilsynet concludes with professional uforsvarlighet, and we take criticism very seriously. This has been a burden for the relatives, the staff and our brand, ” says Fiane to VG about the report.
He points out that the national hospital has operated with advanced transplants in almost 40 years, but that it is the first time they’ve ended up in such a situation.
– This has created a lot of discussion and given us a number of things to ponder when it comes to the improvement and due diligence in relation to the control and communication, and checklists to avoid such. We have had internal audits, checked to see if we have followed the new policy and established more specific functional descriptions for those involved, and how this communication will take place, says Fiane.
– But how could this happen?
– There are complex things we deal with, and we have lent us heavily on individuals. But those involved acted in good faith. When you know each other well, so can the communication become less. It can city at risk during complex procedures, because then misunderstandings occur.
His team at the national hospital reported to the State board of health after a mistake was made. But the fatal failure was never reported to the police such a policy implies. This is likely because the man first died after a few weeks, according to Fiane.
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