Becker's Clinical Quality & Infection Control

20 PATIENT SAFETY & OUTCOMES Washington physician charged with unprofessional conduct after patient dies By Ayla Ellison T he Washington State Department of Health charged a physician with un- professional conduct after he alleged- ly failed to test a patient for heart problems, and the patient died days later of cardiac arrest, according to the Tri-City Herald. The health department announced the charge against Jared Guenter Wolfert, DO, in January. He was charged in No- vember 2020, but the death occurred in 2018, according to the report. Dr. Wolfert, who practices at Richland, Wash.-based Kadlec Regional Medical Center, disputes the charge. According to the health department, a 58-year-old man with chronic obstruc- tive pulmonary disease and high blood pressure was brought to the emergency department in mid-November 2018 expe- riencing back pain, near loss of conscious- ness and unusual sweating. The health department said there is no evidence that Dr. Wolfert performed tests on the patient to determine if his symp- toms could be caused by heart issues. The physician discharged the patient from the ER with prescriptions for an anti-inflamma- tory and a muscle relaxant, the state said, according to the report. The patient went into cardiac arrest shortly after he was released from the ER, and he died two days later. In January, Kadlec said it could not com- ment on the matter because the investiga- tion was ongoing. "Kadlec is dedicated to the highest stan- dards of patient safety," Kadlec said in a statement to the Tri-City Herald. "We take any and all concerns about patient safety extremely seriously and fully investigate as appropriate." As of January, Dr. Wolfert was employed at Kadlec through a contract with a physician staffing company. n Woman dies 2 months after contracting COVID-19 from donor lungs By Erica Carbajal A woman with chronic obstructive lung disease contracted COVID-19 from a pair of donor lungs and died 61 days aer the transplant — the first con- firmed donor-to-recipient transmission of COVID-19 in the U.S., accord- ing to a case report published Feb. 10 in the American Journal of Transplantation. e transplant was performed at the University of Michigan Medical School in Ann Arbor. e thoracic surgeon who prepared the donor lungs for implantation and who performed the procedure also tested positive for COVID-19, while 10 other healthcare personnel present during the procedure were negative. Polymerase chain reaction testing was performed before the procedure. e donor, a woman who died from severe brain injury aer a car accident, tested negative 48 hours before procurement, and the recipient tested negative 12 hours before the transplant. ree days post-transplant, the recipient developed a fever and hypo- tension, while imaging suggested a lung infection. Physicians took a bronchoalveolar lavage fluid sample from the recipient for test- ing. e method entails obtaining specimens from deeper in the lower respiratory tract than the nasal swabs used for PCR testing. e sample came back positive, as did a lung fluid sample taken from the donor during procurement. At the same time, a second PCR test was performed on the recipient and did not detect a COVID-19 infection. Genetic sequencing confirmed the donor lungs as the source of the recipient and surgeon's COVID-19 infection. "Transplant centers and organ procurement organizations should perform SARS- CoV-2 testing of lower respiratory tract specimens from potential lung donors, and consider enhanced personal protective equipment for healthcare workers involved in lung procurement and transplantation," the physicians said. n Patient lift recalled after 2 deaths By Maia Anderson H illrom, a medical devicemaker in Chicago, recalled its patient overhead lift device after multiple reports of serious injuries and two patient deaths. Hillrom is recalling its Liko Multirall 200 Overhead Lift, used to move patients from room to room in hospitals, rehabilitation facilities and nursing homes, due to customer reports that the strap doesn't attach to the hook properly. If the strap doesn't attach, the motor or patient may fall, which could cause serious injury or death. As of February, the company had received 34 complaints about the device, 22 reports of serious injuries and two reports of patient deaths. The FDA said Feb. 22 that it has classified the recall as class 1, the most serious type. n

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