“Where is the kidney?” According to new information from the University of Toledo Medical Center, this is what the operating surgeon said when he turned away from the kidney donor to take the kidney to another room to continue the transplant procedure. The kidney had mysteriously disappeared from a designated ice bin in the operating room.
A moment later, a nurse walked back into the operating room after disposing of surgical waste. The doctor asked her again, “where’s the kidney.” The nurse’s response: “Oh my god, I flushed the kidney.” As it turned out, the nurse accidentally threw the donor’s viable kidney away. Doctors were unable to salvage it and the recipient had to continue waiting for another compatible organ.
After this shocking example of possible medical negligence occurred back in July, the transplant facility took several months to release more details about what happened. Apparently, hospital procedures called for nurses to place donor kidneys in an unmarked metal basin in an ice machine. The hospital has now changed its transplant policies.
For example, transplant organs now go into a plastic box marked with a clear label. Nurses are also forbidden from disposing of anything until after the surgery is completely finished. The ice bin even has an alarm to warn the rest of the operating room that a person is approaching it.
While the hospital defends its conduct by saying that inevitable mistakes are an opportunity to improve care practices, critics respond by saying that safeguards already exist to prevent errors like this. Another transplant doctor said that his hospital already used a similar practice of immediately labeling transplant organs. That facility goes a step further by requiring surgeons to keep the organ within their sight and control at all times.
Medical mistakes like this may be an opportunity for improvement for hospital staff-but for the patients who have to suffer the consequences of these errors, the opportunity is already wasted.
Source: Toledo Blade, “Changes in place after botched surgery,” Jennifer Feehan, Oct. 7, 2012