Transplant oversight lax, report concludes

LOS ANGELES – The organization that oversees the nation’s organ transplants frequently fails to find or fix problems at hospitals under its supervision, according to a newspaper investigation published Sunday.

The United Network for Organ Sharing has even failed to act when patients were dying at abnormal rates, and often has kept its findings secret when it does investigate problems, the Los Angeles Times reported.

The federal government contracts with the nonprofit UNOS to oversee the entire transplant process, from the harvesting to the placement of organs. The organization can censure hospitals and recommend their closure.

But UNOS has never recommended closing an active transplant program, and it has been reluctant to take action of any kind against troubled hospitals, the Los Angeles Times concluded after reviewing documents and interviewing current and former board members.

“It seems like UNOS is often a day late and a dollar short,” said Dr. Mark Fox, former chairman of UNOS’s ethics committee. “Most people are kind of shaking their heads and saying, ‘Who’s minding the store?’”

The agency’s executive director, Walter Graham, acknowledged that the “sense of outrage has grown in the transplant community” and said changes were being made.

UNOS sometimes took years to follow up on reports of excessive deaths, according to the newspaper’s investigation.

At Sunrise Medical Center in Las Vegas, UNOS was aware in 2002 that patients were dying at unacceptably high rates but did not investigate for four years.

Problems with two California transplant centers escaped the organization’s notice despite warning signs, including statistics available on its own Web site.

In response to the criticism, the UNOS board recently voted for reforms, such as publicizing the names of transplant centers on probation. But officials from the organization said resolving matters peacefully works better than issuing demerits.

Since 2000, UNOS has considered its most serious public sanction – revoking a transplant center’s “good standing” – 15 times, but has followed through only once.

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