Melting Ice Led To Tragedy

By Scott Fornek

Staff Reporter

The organ bank that mistakenly sent a heart to a Downstate kidney patient who later died said Wednesday the problem stemmed from a label that was ruined or came off the packaging of the kidney he was supposed to receive.

Hoping to avoid such mishaps in the future, the Regional Organ Bank of Illinois pledged to use better adhesive labels and waterproof markers on the boxes in which it ships organs.

"That will not eradicate the possibility for human error--nothing will do that--but we are confident what we did is an adequate response to this," said Alison Smith, vice president of operations for the Regional Organ Bank of Illinois.

It is the first such blunder in the nation, where about 180,000 transplants have been done since 1987.

The bizarre case has prompted the federal agency that oversees the nation's organ transplant system to launch an investigation into the botched organ delivery.

"We want to find out the facts and take all appropriate actions regarding the death of John Sherman," said Dr. Jeffrey Kang, chief clinical officer for the U.S. Health Care Financing Administration.

"I want to make sure that we understand the circumstances surrounding this tragic event and take all appropriate measures to prevent anything like this from happening again."

Sherman, 31, of Easton, died Sunday at Memorial Medical Center in Springfield. He had been hospitalized there since May 12, when he was supposed to undergo a kidney transplant. Sherman was on the operating table when the surgeon realized the organ bank had sent him a heart instead of a kidney.

"I was stunned," said Dr. Timothy O'Connor, Sherman's surgeon.

"I have never heard of it happening before," said O'Connor, director of the joint kidney and pancreas transplant program at Southern Illinois University and Memorial Medical Center.

The United Network for Organ Sharing, which coordinates transplants for the federal government, had no record of such a blunder since the system began in 1987.

"The system is a very controlled system," spokesman Bob Spieldenner said. "The people involved are professionals. Unfortunately, mistakes sometimes happen, but everything is done to try to prevent that."

The mix-up occurred while an organ recovery coordinator for the Regional Organ Bank of Illinois was transporting two kidneys and a heart from a Chicago hospital to the regional bank's South Loop headquarters. The organs were wrapped in plastic, placed in jar-like containers, sealed in cardboard boxes and placed inside a cooler, bank spokesman Dave Bosch said.

The heart had no label on the outside of its package because it was going to a research laboratory--not a transplant patient, Smith said. The packages containing the kidneys did have outside labels, but moisture from ice in the cooler caused one "to be either unreadable or caused it to fall off."

The worker discovered the problem and checked labels inside the packages before affixing new labels, but "somehow in the process of reaffixing the labels, the two labels got switched," Smith said.

Smith said they have begun using labels that are less permeable to water, waterproof marking pens and "a plastic overcoat" over the entire label to keep water out. She said they have asked some surgeons to review their system to see if other changes are needed.

O'Connor and the hospital said they could not discuss the cause of death or Sherman's medical history without the permission of his family.

One of Sherman's relatives said the family would not be speaking to reporters until some time after his funeral, scheduled for 11 a.m. this morning at a cemetery in Downstate Havana.

Sherman was on Social Security disability because of his kidney problems, which he had since he was about 9, said his friend, Daniel DeVore Jr. Sherman lived with DeVore, DeVore's wife and son and DeVore's parents. Sherman was unmarried and had no children but was godfather to the DeVores' 5-month-old son, Dale.

"I loved John dearly," said Anna, 20, DeVore's wife. "I just feel bad for my son, now 5 months old. He lost his godfather. Dale meant a lot to John. He was so excited about the baby, and he hated being away from him when he was in the hospital."

Copyright © 2000 Digital Chicago Inc.

This article posted June 21, 2000.