Lunch break mix-up led to transplant kidney in trash - 13abc.com Toledo (OH) News, Weather and Sports

It seems very simple, one nurse leaves for lunch, another covers for that nurse.  Lunch is over.
They both talk about where the procedure stands. That's not what happened at UTMC, according to a report from the Ohio Department of Health.

On August 10 of this year, the patient comes to the University of Toledo Medical Center to give the kidney to a family member.  That never ends up happening.

According to the report by the Ohio department of health, one nurse, listed at nurse A, in the room at the beginning leaves for lunch at 12:15.  She was not in the room when it was announced that the kidney was put into something called the slush machine where it is preserved.

Another nurse, Nurse B, was in the surgical room when that was announced. Nurse A comes back from Lunch disposed of the content of the slush machine into the "hopper." Which included the kidney.

The nurse that went on lunch, Nurse A, says she thought the kidney was in the recipients room because she says that's what usually happens.  Nurse A and Nurse B did not communicate about where the kidney was after the lunch break ended, according from the report.  

After several interviews no one said they saw nurse A empty the slush machine.  A  member of the administrative staff is quoted in the report as saying they could not figure out how no one noticed the nurse taking the slush with the kidney in a 13 gallon size bag, out of the room with no one noticing.  

Further review showed that the process of not removing anything from the room until the drapes are removed from the patient were not followed.

According to UTMC the remaining nurse on administrative leave, Melanie Lemay has been terminated.  Another nurse has already resigned and an administrator is back to work after he was out on paid administrative leave.

Click here to view the report. 

Click here for more documents.