Bungled operation sparks organ transplant debate

Rosmarie Voser is pictured here just before her fatal operation. SF DRS

The death of a transplant patient who was given the wrong heart in an operation last week has led to a surge in interest among potential donors in Switzerland.

This content was published on April 27, 2004 minutes

But it has also raised serious questions about how such a mistake could have been allowed to happen.

Rosmarie Voser died on Friday after doctors at Zurich University Hospital gave her a new heart incompatible with her blood group, which her body then rejected.

At a media conference on Tuesday, the hospital admitted human error was to blame for the death of the patient.

Hospital director Christiane Roth blamed communication problems within the hospital’s organ transplant team.

She said no more transplants would be carried out for at least the next two months while an internal investigation is carried out.

Roth said preliminary findings ruled out data inputting errors or mistakes in laboratory testing as explanations for Voser’s death.

TV coverage

The 57-year-old Voser had been in hospital for three months awaiting a transplant.

She was the subject of regular reports on Swiss television’s current affairs programme, “10vor10”, which followed her as she waited for the operation and up until moments before the failed heart transplant.

The national transplant coordination centre, Swisstransplant, said the publicity surrounding Voser’s death had prompted a flood of requests from the public for information and donor forms.

“We have seen an amazing increase in interest… and have done nothing else but answer enquiries from the public since news broke of the patient’s death last Friday,” said Britta Johnson, administrator and public relations manager at Swisstransplant.

Johnson said Swisstransplant had initially feared the incident would hinder efforts to increase the number of organ donors in Switzerland.

“We were concerned that people might take it badly, but they have understood that there is a real lack of organs in Switzerland,” she said.

The president of Swisstransplant, Trix Herberlein, said the public’s reaction suggested that Voser had not died in vain.

"It was her intention to show people how few organs we have in Switzerland and how many people are waiting for an organ donation. After the regrettable death of Mrs Voser, Swisstransplant had many, many requests for donor cards - and for information about organ donation - which I think was one of her wishes."

Few donors

Compared with other European countries Switzerland has a poor record in organ donation. In 2002 just 13 out of every million Swiss were donors.

Sixteen patients are currently awaiting a heart transplant in Switzerland.

Heberlein, a parliamentarian for the centre-right Radical Party, called for more donors to come forward, saying that the lack of organs for transplant led to more than 50 deaths a year.

"But of course an organ donation always implies that you have had a patient die in an accident or die of a brain haemorrhage, and fortunately the accidents that lead to a death have been reduced, so that's one of the reasons," Heberlein said.

Since Voser’s death, another case has come to light of a patient in a Swiss hospital being given an incompatible heart.

The incident in 1997 involving a 19-year-old patient at Bern University Hospital was never publicised.

But thanks to swift detection of the mistake, doctors were able to stop the patient’s body from rejecting the heart, a hospital spokesman said on Tuesday.

Meanwhile, the Swiss Foundation for Patient Safety has called for a nationwide study into medical errors in Swiss hospitals.

It says international surveys show that things go wrong for up to 16 per cent of patients, but that in more than a third of cases these “untoward occurrences” could be avoided.

swissinfo, Morven McLean

Key facts

According to Swisstransplant, 11 heart transplant operations were carried out in Switzerland between January and March 2004.
16 people are awaiting a heart transplant.
A lack of organs for donation results in the deaths of more than 50 people in Switzerland every year.

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In brief

Rosmarie Voser died after doctors at Zurich University Hospital gave her a heart with the wrong blood group.

The hospital says a preliminary investigation shows that communication problems within the transplant team were to blame.

Transplants will not be carried out at the hospital for at least the next two months while procedures are reviewed.

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