Senate review blames deaths, illnesses on mistakes in organ transplant screening

The Senate Finance Committee released a report Wednesday linking dozens of deaths and illnesses to a lack of oversight from the organization in charge of overseeing organ transplants in the U.S.

The congressional committee linked 70 deaths caused by donor-derived disease to a lack of oversight from the Organ Procurement and Transplantation Network (OPTN), which is the organization in charge of overseeing organ transplants and testing in the U.S.

The committee’s investigation found that the OPTN failed to provide adequate oversight, resulting in fewer available organs for transplant. The OPTN is overseen by the United Network for Organ Sharing (UNOS), a nonprofit organization the Finance committee said was responsible for “avoidable failures” that resulted in viable organs being lost or destroyed.

The UNOS has been the only contractor to have or bid for the OPTN contract offered by the Department of Health and Human Services in the network’s nearly 40 years of operation.

Between January 2008 and September 2015, it was discovered that 211 donors transmitted diseases through their organs and 249 recipients developed donor-derived diseases. Of the 249 who developed diseases from their donated organs, 70 died.

“This data illustrates the lethality of diseases contracted during a transplantation and the need for exacting scrutiny of such transmissions,” the committee wrote.

These deaths represent a relatively small percentage of the thousands of transplants performed every year. Roughly 20,600 organ transplants are believed to have been performed just this year as of June.

Other organ recipients were harmed or nearly died due to error, with the Senate panel pointing to multiple instances where patients received organs with the wrong blood type. Several other organs were negatively impacted by transportation failures and could not be transplanted.

The OPTN is also in charge of overseeing 57 organ procurement organizations (OPOs), which are not-for-profit organizations that procure viable transplant organs from deceased individuals. The committee’s investigation was first launched over concerns that OPOs were failing to procure thousands of viable organs.

The report noted that the Centers for Medicare and Medicaid Services recently issued a rule changing the way that OPO performance is evaluated. Under the new evaluation method, 22 out of the 57 OPOs would fail to meet expected outcomes and be decertified.

“The Committee’s investigation shows that despite the efforts of UNOS and its internal committees, OPOs continue to experience recurring and systemic patient safety issues, including packaging and labeling errors, transportation failures, failure to identify transmissible diseases in donors, and even allegations of fraud,” read the report.

The panel issued several recommendations on the basis that the U.S. transplant network was not working “from the top down,” including enhancing transparency and accountability in the organ procurement process. Many recommendations were made to increase the pool of potential bidders for the OPTN contract.