By: Anne Hart
Why did a nurse accidentally toss in the garbage a kidney just removed from a living donor and destined to be transplanted into the donor’s sister? Poor post-operative surgical care is one of the biggest problems in American hospitals. An estimated 100,000 hospital patients die every year as a result of medical negligence or malpractice. The error made news headlines, but the question is what communication had been missing and who was responsible to inform the nurse that the kidney was not post-surgery parts to be trashed?
When a nurse accidentally — by human error — threw away a kidney just removed from a living donor, a kidney supposed to be transplanted into the male donor’s sister who needed a kidney transplant, what happens next to the sister, the living donor, her brother, the nurse who threw away the kidney by error, the hospital, physicians, and anyone else who was supposed to tell the nurse that the kidney was not supposed to be tossed in the garbage?
Something is missing — the person who’s supposed to tell the nurse that the kidney is not garbage you’re supposed to clean up after surgery, that the kidney is not meant to be disposed of in the trash. Why didn’t the nurse know about the transplant or what the kidney was and how it was supposed to be kept viable? Didn’t anyone come over in person and tell the nurse what the procedure is going to be?
An estimated 100,000 hospital patients die every year as a result of medical negligence
What causes human error — a cognitive or a medical reason? The answer usually is miscommunication caused by lack of communication at the immediate time and place of the event such as an organ transplant. When a brother as a living donor gave his kidney to his sister who needed a transplant, a nurse accidentally dumped the kidney in the trash. According to the article,Surgical Mistakes, an estimated 100,000 hospital patients die every year as a direct result of medical malpractice or medical negligence involving surgical mistakes by surgeons and other health care professionals in operating rooms.
Did the hospital rely on a note that may not have been seen? Was there a staff person missing in the communication chain? And why was the kidney not supervised at all times by someone who knew the destination, the end result of that kidney? What could have prevented the human error? Not a note or email, because the nurse may have not thought of reading the note at that time.
Why wasn’t the kidney supervised by a team from the moment it left the body until it was transplanted into the man’s sister? The sister and brother, according to news reports, have been discharged from the hospital — he with one less kidney, and his sister, still in need of a transplant.
The most important step in the surgery process had been overlooked — keeping the kidney viable
The reason is because nobody stood in front of the nurse and said to the individual “This kidney has just been removed from a living donor to be transplanted into the man’s sister. It has to be prepared in a specific way to keep it viable.” Nobody said that immediately to the nurse’s face. Would physicians change inpatient treatment if presented with the results of a literature search on how many human errors are made frequently in hospitals, especially during or right after surgery?
Instead the kidney was immediately in an unsupervised position, left alone for a moment, which is the reason why human error usually happens. The vital organ is not supervised from the time it leaves the living donor until it becomes transplanted. During the waiting time that the organ has to be kept viable, kept alive, it must be supervised every moment.
That protects the organ from a person coming in to clean up and tossing out the organ thinking it’s garbage left after an operation. Not all medical or human errors are reported in the media, according to the study, “The Impact of Evidence on Physicians’ Inpatient Treatment Decisions,” Journal of General Internal Medicine 19 (5 Pt 1): 402–9.
What happened a few days ago focuses on human error. An Ohio nurse accidentally put a kidney in the trash, prompting the University of Toledo Medical Center to suspend its live donor program as it investigates the incident, according to the August 25, 2012 ABC News report by Alyssa Newcomb, “Kidney for Ohio Transplant Thrown in Trash.”
The kidney became unusable after being tossed in the garbage
Doctors tried to resuscitate the kidney, which came from a live donor, but it was rendered unusable. Can you imagine the intensity of feeling from a living donor who gave his kidney to save the life of his sister, and finds out when he wakes up that the kidney had been accidentally thrown out by a nurse?
The hospital has voluntarily suspended its live kidney donor program and has placed two nurses on paid administrative leave while it investigates the incident. Presently, the hospital is assessing how this situation occurred. But what safeguards will be put in place the next time human error happens?
How could have the hospital have prevented the human error?
Presently, the hospital is turning to experts to see how it can prevent this type of human error again. The University of Toledo Medical Center has performed more than 1,700 renal transplants since it began in 1972, with a 98 percent success rate, according to the hospital. A spokesperson said the transplant program is expected to reopen in the next few weeks, according to the ABC news report.
Medical errors are associated with inexperienced physicians and nurses, new procedures, extremes of age, complex care and urgent care, according to the 2000 study, “Epidemiology of medical error”. BMJ Publishing Group. Retrieved 2006-03-17. The reason for human error usually is poor communication. You also find medical error occurring in places where medical tourists have language communication problems when they opt for cheaper surgery in other countries.
Regardless of where the surgery is done, errors happen due to improper documentation, illegible handwriting, inadequate nurse-to-patient ratios, and similarly named medications. There’s also the problem of patients being given too much radiation because no one looks at the settings or knows how much radiation is given at a specific setting that puts the patient at risk of toxic doses.
Sometimes hospitals even blame the patient for medical errors
Patient actions may also contribute significantly to medical errors. Falls, for example, are often due to patients’ own misjudgments. Check out the study, “Exploring the causes of adverse events in NHS hospital practice”. Journal of the Royal Society of Medicine 94 (7): 322–30. Human error has been implicated in nearly 80 percent of adverse events that occur in complex healthcare systems.
The vast majority of medical errors result from faulty systems and poorly designed processes versus poor practices or incompetent practitioners, according to the 2008 study, “The anatomy and physiology of error in averse healthcare events,” Advances in Health Care Management. Advances in Health Care Management 7: 33–68.
Human errors happen daily in hospitals ranging from an instrument such as a scissors or sponge being sewn up inside a person after surgery to gauze rags being left inside women after childbirth. You read in newspapers about the wrong limb being taken off during surgery or someone dying because the surgeon’s scalpel accidentally nicked an artery. You hear news of patients being given the wrong drug by a pharmacist or administered the wrong medicine by a nurse, or getting an infection because an IV wasn’t cleaned properly.
What do surgeons say is acceptable when a mistake is made?
In the article, “Some Worms Are Best Left in the Can’ — Should You Hide Medical Errors?,” by Gail Garfinkel Weiss, posted at Medscape Medical Ethics on January 4, 2011, the author writes, “A survey of more than 10,000 physicians in the United States came to the results that, on the question “Are there times when it’s acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?”, 19% answered yes, 60% answered no and 21% answered it depends. On the question, “Are there times when it is acceptable to cover up or avoid revealing a mistake if that mistake would potentially or likely harm the patient?”, 2% answered yes, 95% answered no and 3% answered it depends.”
This article was written by Anne Hart and originally published on examiner