10-15-2016, 01:42 AM #1Registered User
- Join Date
- Jul 2011
MA Hospital faulted for removing kidney from wrong patient
"State and federal health investigators say the surgeon in July was supposed to remove a kidney with a tumor from a patient at St. Vincent Hospital in Worcester, but instead removed a healthy kidney from a different patient with the same name.
"Authorities say the hospital failed to follow proper patient identification protocols by checking birth dates. The patients were several years apart in age...."
http://centurylink.net/news/read/art...om_wrong_pa-ap Oct 14
Last edited by beach; 10-16-2016 at 02:36 PM. Reason: absolutely not going to permit ANY of those comparisons completely irrelevant to the linked article
10-15-2016, 11:00 AM #2Registered User
- Join Date
- Oct 2014
- State of Bliss
I was taught in school there are no mistakes in nursing. But then we had an entire lecture series on reporting errors, lol. Asking for a date of birth is 101 in the hospital setting. I've made many errors, for various reasons, but in the end I was the only one who could be held accountable. Even if the pharmacist sends a mislabeled Med, it's my fault if I give it. Still trying to get over that one from my first year as a nurse. There are protocols and procedures out the yazoo for everything, and sometimes they just aren't followed properly for various reasons. I have seen few medical staff ever terminated in almost 20 years of working due to errors. But, I haven't seen anything this incompetent. (That I know of).
Last edited by beach; 10-16-2016 at 02:49 PM. Reason: and you shouldn't even try to compare it because it is TOTALLY irrelevant, as you pointed out. :)
10-15-2016, 06:32 PM #3
Al66pine, I honestly can't even fathom how such an error could occur with all of the modern checks and balances in operating room care. I'm an anesthetist now, but I flew airevac with the USAF for many years, both active duty and reserves, and "crew resource management" in the aerospace and military industries is the same process that is needed and practiced now in surgery. In surgery, it's called "The Universal Protocol."
This is a 283 bed hospital, so not small or "backwards" by any stretch. They would not be using "paper" charts in a 283 bed hospital in 2016. The computer charting systems are incredibly complex, with checks, balances, and alerts. The physician alone does not bear all of the responsibility for this incredibly incompetent occurrence. This patient, even if checked in as an outpatient, would have been fully in the system with labs, preop, radiology, billing, etc. LIterally dozens of people had to fall down on the job for such a thing to occur-- and that includes the "time out" with the full team that is required before each and every procedure. I'm not saying it didn't happen, because clearly it did. I just cannot even hypothesize how a "wrong site, wrong patient" surgery could get this far in 2016. This was a complete failure of "crew resource management" principles at the highest level.
Did no one in the preop area interview the patient? Was the patient from another clinic system, and the records weren't properly in the new system? Were there any family members with the patient? Did no one from Anesthesia even talk to the patient? Did the circulating RN talk to the patient? Did ANY of them look at the chart? The office preop? The specialist H & P? The labs? The DOB? Name alerts? This wasn't an emergency case-- it was elective. I really struggle to try to imagine what kind of situation could get so far so wrong, that the patient is asleep and positioned for surgery, and the wrong kidney is actually removed?? Did no one notice that the "good" kidney looked "good" and not diseased when they had visualization? How, how, how, can something like this happen?? It truly boggles the mind, and I've worked in literally dozens of hospitals, as a locum tenens, and full time.
There is a really good book about systemic failures in healthcare, industry, and aviation, written by a physician. It gives a lot of insight into how systemic failures occur, and the "cascade of errors" that usually has to happen before something catastrophic occurs. These have to be "never" situations, and we have to thoroughly investigate why they occurred. In the past, QA/ risk management was all about "name, blame. and shame." We have evolved our thinking in healthcare somewhat so that the end is not "shame", but "fix, change, and prevent".
Last edited by K_Z; 10-15-2016 at 06:40 PM.
10-15-2016, 06:55 PM #4
Ah-- here is more detail on the "wrong kidney" surgery:
According to the 32-page report, on July 20, the patient was at St. Vincent to have the left kidney removed because of a large tumor.
During the surgery, it was determined that the patient’s kidney did not have a tumor. The kidney was sent to the Pathology Department which notified the surgeon that the kidney did not have a tumor.
“It was later determined that (the patient’s) admission and plan for surgery to remove the tumorous kidney was based on another patient’s Computerized Tomography (CT) scan results, in error,” the report read.
The Operative report revealed that there were two patients with the same name who had CT scans at another hospital on the same day in June and their birth dates were a few years apart.
After the error was publicized in August, Ms. Noonan said in a statement that the patient's outside physician misidentified the procedure the patient needed before he was brought to St. Vincent. The patient's physician scheduled the surgery at St. Vincent Hospital.
The internal investigation done by the hospital determined that the medical record of the patient who was mistakenly operated on did not contain a CT scan report, one of the methods the hospital uses to confirm a patient’s diagnosis, the investigation found.
Nurse practitioners, who are responsible for the assessment of the patient’s condition and needs, who were interviewed, said the pre-admission testing unit did not always receive reports and physician notes prior to their assessment of the patient before surgery.
To correct that, the hospital plans to have “all surgical cases which are deemed clinically necessary based on an imaging study, have the images available, present (displayed) prior to the surgery to verify the patient’s name, date of birth, surgical site and side..."
The hospitals I work in are so concerned about "wrong site" that they are taking photos of the sites marked preop as part of the chart, as well as taking intra operative "before and after" pictures of the organ or exposed surgical site for the charts with digital cameras. It's easy to do that with laparoscopic cases (the camera has the ability to snap stills or video), and now we're using digital cameras much more to document every step of the case in the OR.<modsnip>
I'm guessing this may have been a general surgery case, where the surgeon did not see the patient in clinic before he was scheduled for surgery. Just scheduled based on the outside doc's report.
Perfect example of a "cascade of errors."
Last edited by beach; 10-16-2016 at 02:34 PM. Reason: removed reference to something completely irrelevant (ref in OP originally)
10-16-2016, 02:43 PM #5
uh...I felt like I stepped into a maze in a house of mirrors I was so confused while reading this thread. Then I saw others were as confused as I was. Finally, after reviewing the OP and original title, I had my "aha! moment" and "got it".
ALL posts referencing anything other than the content contained in the linked article have been removed. It best stay on topic from here forth.
10-16-2016, 10:30 PM #6Registered User
- Join Date
- Jul 2011
10-20-2016, 01:31 AM #7
Since I have never worked in any sort of capacity in a hospital or even physician related setting I have no idea what they do or dont do before a patient would go in for a procedure. It is comforting to hear that there should have been many checks and balances along the way.
Including one of the most obvious ones that should have been followed and this one I have personally seen this one being used when I was escorting a relative for a procedure. The nurses just verbally talked with the patient and asked some simple and obvious questions to confirm the patient was knowing what they were there for and what the staff was about to do.
They asked my relative simple questions like
-You are here today to have procedure XXXXX done is that correct?
That most basic of procedure checks would have and should have caught this mistake they made well before it happened. So I agree with you that I am flabbergasted as how this could have happened other than the simply obvious thing which is probably what did occur.
They didnt follow some of the most simplest parts of their own protocol in ensuring the patient was who they thought it was.
Can you just imagine waking up afterwards and being brought to only to have a nurse or doctor standing over you to give you the bad news?
No, lets not try to imagine that horror. Lets just pray for the person that had this happen and hope they are a forgiving soul and lets hope that they live a long fruitful life without the organ that was removed.
10-20-2016, 01:17 PM #8
Now we know, from articles I linked above, that the primary error that produced this incredibly unfortunate cascade of errors did not originate at the hospital that performed the surgery. However, that doesn’t excuse the error at all, as I’ll explain.
I’ll briefly summarize.
Two patients with similar names (A and B) had CT scans at hospital #1 weeks or months before the wrong-patient surgery at hospital 2. Hosp 1 mixed up the similarly named patients, A and B, in their computer system somehow. The doc who originally ordered the CT scan for patient A actually received the results for patient B. (And this happened almost certainly after a third party radiologist read and interpreted the scan.) At this point, we don’t know if the scan with the tumor was actually assigned to the correct patient, or the name-similar patient—and that is a very crucial point in this cascade of errors. If the scan was mis-assigned to the wrong patient, there is actually no way to determine that an error occurred unless ANOTHER scan was taken for comparison. (BTW, I think that will end up being the “fix” at the surgical hospital, as it is at many hospitals now—they will no longer accept outside scans, due to the potential for relying on them in error. So health care costs go up again.)
Anyway, moving on. Based on the findings in the “wrong” CT, the doc scheduled patient A for surgery at hospital 2 with a specific surgeon. It’s unknown at this point whether patient A actually saw the hospital 2 surgeon in the office for a clinic visit before surgery, or if patient A was just put on the OR schedule and processed into the system that way.
During the pre-op work up at hospital 2 (days to weeks before the actual surgery) the preop nurse did not have access to the original CT scan from hospital 1, but continued to process the patient into the system for scheduled surgery. (This is not terribly uncommon—there is often a lag in receiving reports and records from outside hopsitals, and it would not delay surgery anywhere I’ve ever worked.)
It is unknown if the operating surgeon knew about this, or ever had the image or CT report from hospital 1. It is unknown who did the 30 day prior preop H & P, and if that provider was part of hospital 1 or 2, and if that provider had the image or report from hospital 1. The preop nurse apparently proceeded with scheduling the case based on the outside reports. Regardless, the ultimate responsibility for consulting and confirming the procedure BEFORE elective surgery rests with the operating surgeon, and that includes evaluating imaging and related reports.
The day of surgery, the patient went to hospital 2, was processed in, and went to surgery. The only thing in error was that the patient’s records did not have the images from hospital 1, but probably had the radiologist report, IMO. The report would not indicate the “name alert” problem that originally occurred. Surgeon opens, doesn’t see a huge tumor, probably thinks it’s a more diffuse internal tumor, removes kidney, and sends to path. Path says no tumor—not sure if that report came in “real time” while patient A was still in surgery, or if path report came hours later.
Patient B from hospital 1 still needs treatment for kidney tumor. Hopefully that patient was identified and began treatment.
10-20-2016, 02:06 PM #9
Why would a surgeon not do a scan or X-ray of kidney after opening patient and observing a healthy kidney?
It could of been that the radiologist made a mistake on his report since the surgeon had no pictures to go by.
Miracles do happen by the Great Doctor. I personally have seen a person taken into surgery, the place to be operated on was totally gone. The surgeon was in awe!
This is a frightening event that a trained surgeon would take out what in his opinion appears to be a normal kidney, This hospital and surgeon are in for a big lawsuit! I hope the patient wins big time! Of course, money will never replace his healthy organ that was removed.
My opinions only.
Last edited by 1&2&3; 10-20-2016 at 02:17 PM. Reason: Typo
10-20-2016, 02:36 PM #10
Well, first, not every kind of tumor is "visually" perceptible in the OR-- some are more diffuse. I have no idea what the original radiologist report said, so it's hard to tell what they thought they were getting into. The surgeon would have had a choice to stop the surgery and close before the kidney was removed, if he thought there was an error. It's likely an intra-op regular xray would not be appropriate to see if there was a tumor.The original CT images "should have" been available in the OR, not just a radiology report, and for whatever reason, the surgeon apparently felt confident he had "enough" information to remove the kidney at the request of the first doc. In these cases, the operating surgeon is a consultant to the primary doc-- more like a technician (though I hate to use that term).
For instance, if a family doc who is doing OB determines that a c/section is necessary during labor, general surgery comes in and does the c/section as asked. The general surgeon will not get into a big long discussion as to whether or not a c/section is indicated, or correct, etc. Even if the c/section is scheduled electively by family medicine, the general surgeon seldom sees the patient ahead of the day it's scheduled. It's up to family medicine to ensure the c/section is still needed (for a breech baby, low lying placenta, repeat c/s for example). Fam docs usually come in the morning of the c/section to do a quick look to confirm the breech in our facilities, or the low lying placenta, etc. Sometimes fam docs gown up with the general surgeon as a sort of "show of support or solidarity", but most of the family docs are not trained and credentialed surgeons, and them gowning and scrubbing is so they can take over the baby evaluation/ resuscitation during the c/section (who will become their patient once born). I've never met a general surgeon anywhere that "needs" the family doc in the OR-- it's strictly a courtesy. If the family doc isn't there, baby eval and management happens just fine with the usual providers, just as when an OB does the c/section (they don't do baby eval and management).
But see, there is a more insidious nature of the problem that happened with the CT images in the kidney case. If the original report was somehow assigned in the computer system at hospital 1 to the wrong patient (which is what happened, I think), it would have the surgical patient's name and identifying information on it, and no one would be aware that it was the wrong report or image. There would be no way to double check.
What I think happened is that when the 2 patients originally got their CT scans at hospital 1, whomever set up the records in imaging went by name, and not birth date, or patient ID number, so the "wrong" patient info was set up at the time of the image. If that happened, even having the image in the OR would not have prevented the problem. And even if the surgeon had the image in a clinic visit, he'd have no idea it was the wrong one.
I don't know how radiology sets up new records from the registration system at that facility, but I think that's what happened. Sadly, the only "fix" for those kind of errors is probably to repeat the test, get a second opinion, etc. That adds a lot of cost to health care.
10-22-2016, 01:32 PM #11Verified physician
- Join Date
- Jan 2014
I think the critical question, at least regarding surgeon liability, is whether the scans were also mislabeled in the PACS (or whatever digital imaging system that hospital uses). In that case, if the surgeon had reviewed the scan ahead of time, saw evidence on the scan of abnormality which was consistent with the gross appearance observed in the OR, then it may be difficult to fault him/her. This doesn't completely fit the scenario with the majority of renal ca primary or metastatic disease because a mass would be noted on the CT scan and noted on the gross appearance of the kidney. So I somewhat question that scenario did exactly play out, however, there are a few details we're missing for me to comfortably assert that.
10-23-2016, 03:17 PM #12
I work mostly in facilities with less than 75 beds, which is the bulk of hospitals in my region outside the large metro areas. General surgery does nearly all C/S, scheduled or urgent. Several of these facilities have around 50 deliveries a month, and about half to 2/3 are C/S (the high C/S rate is another discussion, but it largely has to do with where the surgeon is, and how fast he/ she can get there, and if the OR crew on call is busy with another case, and the demise of VBACs.) Occasionally I've come across an older FP/ GP that is trained and credentialed for C/S, D & C's, sometimes T & As, but that is increasingly more rare. I worked with one GP that lacerated the bladder during a C/S, and had to have general surgery come in to help. And I had a nightmare scenario at an Indian reservation hospital that DID have an OB, who got in way over his head in surgery, but didn't have a general surgeon for more than 100 miles away, but that's another story all together.)
That said, I completely agree with your comment about the kidney tumor, and how the patient data was initially coded in the radiology record. As I said above, if the imaging record was coded with the wrong information, then that is where the problem began, and no one (the initial doc who ordered the CT, and the operating surgeon) would have had any way to know that the images didn't belong to the patient in front of them.
I want to believe the surgeon DID consult with the original doc, and I also want to believe that the surgeon met with the patient in the clinic before surgery, and at some point reviewed some kind of images (not just the reports). But I agree that there are some gaps in the way this was reported in the media that means we will likely not know exactly what happened (unless it ends up in a professional publication).
I'm not sure how we "fix" these kinds of problems, unless we "require" duplicate imaging to verify, or duplicate verification with imaging. (If it was a patient information data entry issue.) Maybe we have to implement widespread verification measures like we have in the OR, in radiology-- verifying the imaging site/ procedure with several people, verifying the record is coded correctly with the right information by several people, etc. Maybe the problem is rare enough, that would be overkill? IDK.
I wonder if there is a national database that tracks how often "wrong image" mishaps occur, such as the tracking we have for "wrong site" surgery?
Last edited by K_Z; 10-23-2016 at 03:33 PM.
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