A kidney donation recipient died in February, 2013. It was determined that his death was due to rabies – specifically rabies that had been transferred with the donated kidney during the transplant in September 2011. Although infectious disease transmission through transplant – especially rabies – is rare, there is benefit in visually diagramming a root cause analysis of this event in a Cause Map. A Cause Map begins with the specific impacts to an organization’s goals resulting from an incident, and shows the cause-and-effect relationships that led to those impacts.
In this case, the patient safety goal was impacted due to the recipient death. The receipt of organs infected with a disease such as rabies is an impact to the patient services goal. Three other recipients also received organs from the same donor but have not shown symptoms of rabies. Their treatment is an impact to the property and labor goals, due to the cost, time and inconvenience of those treatments.
The impacted goals form the first cause-and-effect relationship in our Cause Map. We ask “Why” questions to determine other cause-and-effect relationships. In this case, the donor death was due to rabies. The donor was infected with rabies from an infected transplanted organ, and was not treated for rabies. The recipient was not treated for rabies as the symptoms did not emerge until a year after the transplant (rabies can have a long incubation period). The donor organs were infected with rabies from an unknown cause, though rabies usually results from contact with wild animals (specifically, this strain of rabies appears to be from a raccoon). The transplant medical team was unaware that the donor had rabies.
Though the donor had encephalitis, it was thought that it was due to a food-borne illness. (Detail on how the diagnosis was obtained has not been released.) While there is testing for certain diseases performed on donor organs, due to the time constraints on the viability of the organ, testing for rabies is not generally performed. However, new guidance from the Disease Transmission Advisory Committee (put out after this donation occurred) urges caution in use of organs from donors with encephalitis, perhaps including more robust testing for specific illnesses, or using only certain organs.
Due to an acute shortage of viable donated organs, some believe that organs from disease-positive donors should be used, and treatment started immediately. With many in need of transplants dying on the waiting list, this may be a more practical approach, though there are certainly concerns about transmitting diseased organs to those who are already very ill, and who will be taking immune suppressing drugs to prevent rejection of transplanted organs, making them more susceptible to such diseases.
To view the Outline and Cause Map, please click “Download PDF” above.
Read our previous blog about a recipient who died of lung cancer after receiving the lungs of a heavy smoker