Hospital Mistakes: Simple Device Could Have Saved Life of Young Kidney Donor

A 28-year-old man tried to save his sister’s life by donating his kidney to her, but instead, lost his own life after surgery.  A Danville family speaks out for the first time about how a simple, inexpensive device could have made all the difference. 

Investigative Unit

Watch Part 1: Simple Device Could Have Saved Life of Young Kidney Donor

A 28-year-old man tried to save his sister's life by donating his kidney to her, but instead, lost his own life after surgery. A Danville family speaks out for the first time about how a simple, inexpensive device could have made all the difference. Jessica Aguirre reports.

Watch Part 2: Dozens of Mistakes Caused Death of Young Hospital Patient, Court Rules

Documents obtained by NBC Bay Area’s Investigative Unit show medical staff at UCSF nearly quadrupled a young patient’s opioid medication and then failed to monitor him with a pulse oximeter, a simple medical device that would have alerted them if his blood oxygen level fell to a dangerously low level. Jessica Aguirre reports.

A BROTHER'S GIFT

When Anders Pederson learned his sister, Kelly, was in kidney failure and would need a transplant, he volunteered to donate to her immediately. Anders was 28 years old and healthy. Kelly had always been his best friend and mentor. "You know people have their partners that are their twin flames. Anders was my twin flame," said Kelly. "We were like twins." Even when Kelly's boyfriend, Mark Jackson, and several other friends said they would gladly donate their kidneys to save, Kelly - Anders insisted. Mark remembers what Anders said, "I appreciate you kind of stepping up for my sister, but it's not you... I'm doing this."

THE TIMELINE

A little after 8 am on a Friday morning in October of 2015, doctors at UCSF made the first incision to remove Anders' kidney and transplant it to Kelly. This was the culmination of a yearlong process of finding the best medical facility and then going through extensive medical evaluations to determine if Anders was a match - and healthy enough to donate a kidney. Melissa Pederson waited anxiously for news. "Oh, it was a long time. It was a long time," she said about the wait. "It was scary." It was nearly 1:30 pm when she heard from the doctors that the transplant had gone perfectly well. But less than 24 hours later, as brother and sister are recovering across the hospital hallway from each other, healthy, 28-year-old Anders, considered by the nursing staff as the "healthiest patient on the floor," went into cardiac arrest. A Code Blue medical team manages to revive him, but nine days later it's clear to everyone that there's too much damage to his brain, and the family is forced to make the painful decision to stop life support.

OPIOID OVERDOSE

The Patient Safety Movement estimates that 250,000 patients die every year in U.S. hospitals due to preventable errors. Many of those errors, said Dr. Mike Ramsay, CEO of the non-profit, are prescription errors. In the case of Anders Pederson, a University of California Pharmacologist would later testify in court that in the hours after surgery, as Anders complained of severe pain, a nurse practitioner changed his medication and made a critical calculation error that quadrupled the dose of opioids Anders was receiving from a patient-controlled dispensing device. CONTINUOUS MONITORING

Dr. William Klein, a board-certified internist with a specialty in respiratory disease, told NBC Bay Area's Investigative Unit that UCSF fell below the standard of care in treating Anders Pederson after surgery. Not only did the hospital fail to check on Anders for nearly five hours as he was succumbing to the effects of the opioids in his system, but the hospital did not put a readily available monitoring device on Anders. Known as a pulse oximeter, the monitor is worn on the finger and can alert hospital staff if a patient's blood oxygen has fallen to a dangerously low level. It can also provide instant information about pulse and blood pressure, both vital indicators of a patient's condition.

HEAR FROM THE FAMILY AND DOCTORS

Melissa Pederson describes how her daughter Kelly’s kidney problems began when she was a baby. 
Melissa Pederson recalls her son’s decision to donate a kidney to his sister.
When her brother insisted on donating his kidney to her, Kelly Pederson worried about his health.
After donating a kidney to his sister, Anders Pederson told his mother it was the best day of his life.
Kelly and Anders had big plans for the weeks they would spend recuperating from their kidney operations.
Melissa Pederson recounts the moments before her son stopped breathing in his hospital room.
As a Code Blue emergency alarm goes off in the hospital, Kelly Pederson feels like she can’t breathe.
Kelly Pederson describes the trauma of losing her brother after he donated his kidney to her.
Dr. Aldo Carmona, Chairman of the Department of Anesthesiology at St. Luke’s University Health Network in Pennsylvania, explains how continuous monitoring of vital signs saves lives.

UCSF Response

The University of California said they could not comment on the Pederson case without violating patient rights but emailed this statement to the Investigative Unit.

https://www.documentcloud.org/documents/21857280-ucsf-statement
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