Ireland hospital removed the wrong kidney from a child
Posted on Oct 27, 2008
The Irish Times reports Our Lady's Hospital for Sick Children in Crumlin, Dublin removed the healthy kidney from a child. The reports indicate the parents even raised questions concerning the side chosen by staff to be operated on. The doctor was a specialist. The hospital had a time-out policy. A time out to some degree occurred or so it was reported afterwards. The child had been anestatized. The parents were present and raised questions. The doctor had previously seen the child as a patient. So what went wrong?
The investigation team identified 10 principal contributory factors to the error.
These included the fact that: the hospital has no site-marking policy to eliminate the risk of wrong-side surgery; an incorrect imaging report from six years earlier had not been identified and corrected; there were delays in filing hard-copy X-ray reports in medical records - one of the child's X-ray reports "had been lost for six months" in the period between the X-ray and admission for surgery; and there was no fail-safe system to ensure a patient undergoing removal of a major organ was discussed in a multidisciplinary setting.
And what was said to be the reason for the error? Here is what the consultant found to be the reasons for errors.
Reasons for error: contributing errors
•A consultant general surgeon wrongly listed a child with a poorly functioning right kidney for a left-sided nephrectomy (kidney removal) after seeing the child in outpatients.
•Concern was expressed by the child's parents about the side of surgery before the child was taken to theatre.
•The operation, removing the wrong kidney, was carried out by a specialist registrar in pediatric surgery who had not seen the patient previously.
•No X-ray images were reviewed prior to or during surgery even when it was noted the kidney being removed looked healthy.
•At the time of the incident Our Lady's Hospital for Sick Children had no formal or universal process to confirm that the correct patient was having the correct procedure, and on the correct side.
•When the wrong kidney was removed from this child the error was realized immediately but it was not possible to put it back.
•Staff felt their workload was a root cause of what happened. There had been an increase in referrals to the hospital without extra staff. Junior surgical doctors worked on average 73 hours a week when not on call and 107 hours a week when on call between January and April this year.
•Often patients are admitted outside normal working hours on the day before surgery, which leaves little chance for their review before surgery.
•Theatres were so busy staff reported the average turnaround time between patients was two minutes.