Case report: Wrong kidney removed
The following text is an extract from a serious incident report carried out after a healthy kidney was removed from a young girl in a Dublin hospital in 2008. The child, XY, had a poorly performing right kidney, but had been listed for a left nephrectomy. She was admitted to hospital the day before the operation and consent was taken for a left nephrectomy, as listed. The parents apparently queried the site of the operation, but, despite this, the operation proceeded as planned on the left side.
The team investigating the underlying causes of the error reported the following findings:
Consent
“Patient XY, who was having a major procedure, was clerked and consented by an SHO who was not competent to perform the operation, and who obtained consent on the basis of what was written in the notes. This would be normal practice within the department, although the majority of surgeons indicated that the formal radiology report should also be reviewed at this point.
Reviewing images
“... In patient XY’s case the imaging was not reviewed at any stage:
“In clinic at the point of listing for surgery; At the point of clerking and taking consent; On the pre-operative morning ward round; In response to the parents’ queries about the operation side.
“In addition the imaging was not reviewed in theatre prior to positioning XY for the procedure or making the incision, and intra-operatively when the kidney was noted to have a healthy appearance.
“... the way in which the hospital’s consent process is structured makes it unlikely that the person obtaining formal consent will be competent to review x-rays, and neither are the films readily available on the ward. Discussions in clinic are not universally treated as part of the formal consent process and it is not stipulated that radiology should be examined at that point.
“... The investigation revealed that it not uncommon practice to rely on radiology reports as a substitute for the images.”
Marking the operation site
“Patient XY was marked in the theatres reception by the SpR, in the presence of the parents, on the basis of a review of the medical records (but not imaging).
“At the time of the incident, [the hospital] had no formal or universal process to confirm the pre-operative checks that should be made to confirm that the correct patient was having the correct procedure, and on the correct side. It was essentially at the discretion of the general surgeons to formulate their own practice, based on internationally accepted standards.
“... It was noted by more than one consultant that they would expect site marking to be done when the patient was clerked and consented, ie on admission to the ward, normally by an SHO. This would mean that site marking could not be done with reference to radiological imaging, as SHOs are not felt to have the experience and competence to review imaging, and it would not usually be present on the ward.
“... Ward and theatre staff commented that in their experience patients may not be marked until arrival in theatre. It would not be unheard-of for a patient to be marked after they have been anaesthetised and positioned for the procedure.”
Source: Independent Review Report published by the Clinical Indemnity Scheme at www.stateclaims.ie