Tuesday, March 18, 2008
Methodist Hospital Removes Wrong Kidney
A major Twin Cities Hospital admitted to a tragic medical error Monday when doctors removed the wrong kidney.
Park Nicollet said it is accepting full responsibility. The error happened last week when surgeons were supposed to take out a patient's kidney because it had a tumor believed to be cancerous.
By mistake, the healthy kidney was removed instead.
"The discovery that this was the wrong kidney was made the next day when the pathologist examined the material and found no evidence of any malignancy," said Samuel Carlson, M.D. and Park Nicollet Chief Medical Officer.
Which meant the potentially cancerous kidney remained intact and functioning.
Because of privacy laws and the family's request, no details about the patient are being released -- not even if the error involves a man or woman, adult or child.
Even though the wrong kidney was removed it's possible this error will not be considered a wrong site surgery. That's because the surgical team did exactly what was asked of it. Their actions were based on an error that occurred weeks earlier.
Surgeons completed the so-called "pause for the cause," a practice when those in the operating room perform a last-minute verification of details concerning the surgery. The surgical site was marked, and every check was followed.
"The mislabeling, or the miscommunication of the side was documented in the medical chart several weeks before the actual procedure," said Carlson.
Still, the surgeon involved has voluntarily stepped aside from any treatment of patients while the hospital conducts what is called a "root cause analysis." No other staff has been removed from duty.
Already, new procedures are in place in Methodist operating rooms.
"As of today, we've implemented a new process that will require our surgical care team to verify laterality using the diagnostic imaging study before the surgery begins," said Carlson.
It isn't known what choices are being made by the patient, but doctors said if a patient has only one kidney that may be cancerous, you either try to save it and beat the cancer, or you have to take it out and start dialysis or consider a transplant.
Kathleen Harder, a University of Minnesota researcher, said medical errors of this magnitude are rare but do happen.
"They remove the wrong ovary, take off the wrong leg," she said. Many hospitals have stepped up efforts to catch errors in the operating room. But as in this case, she noted, the problem can occur long before the operation begins. "It's wrong in the chart... and that sets it up for a train wreck."
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