Surgeon who removed wrong kidney blames distractions

Surgeon who removed wrong kidney blames distractions

By MAURA LERNER, Star Tribune

July 2, 2008

A Methodist Hospital surgeon who mistakenly removed the wrong kidney from a cancer patient in March said he was distracted by beeper calls and other patients when he made the original mistake in the patient's chart, a state investigation has found.

The surgeon also said he failed to read the radiologist's notes to ensure he was operating on the correct side, according to a report by the state's Office of Health Facility Complaints.

The identity of the patient has never been made public. But the report reveals that afterward, he had surgery at another hospital to try to remove the tumor and save his remaining kidney. No information has been released on his current condition.

The hospital admitted the error and issued a rare public apology on March 17, a week after the surgical mix-up. At the time, the hospital said the doctor had voluntarily stopped seeing patients pending the outcome of the hospital's investigation. On Tuesday, the hospital would not comment further on the doctor's status.

But new details have emerged in the report by the health agency, which interviewed the surgeon and others as part of an investigation.

The report says the surgeon, an unidentified urologist, noted a mass "on the left kidney" when the patient's cancer was first diagnosed in January. But surgery was postponed for two months because the patient, who also suffered from heart problems, needed a heart bypass and valve replacement first.

On Feb. 29, the surgeon examined the patient again. This time, the chart notes say the cancer was on the right. The surgeon told the state investigator that he normally dictates his notes immediately after seeing patients but didn't in this case because "his clinic appointments were overbooked," and he "received numerous beeper calls, which also diverted his attention."

By the time he dictated his notes hours later, he had seen two other patients with right-side kidney problems, and "inadvertently substituted the word 'right' for 'left'" in the patient's chart, the report said.

That mistake set in motion a chain of errors, in spite of safeguards designed to catch them. The report said the surgeon "acknowledged that the surgical error on 3/11/08 occurred because the surgeons did not look at the written statement prepared by the radiologist (even though it was available to them)."

Later, the hospital imposed new rules for "mistake proofing" the operating room, including extra steps to doublecheck the images and mark the proper side before surgery. State investigators concluded that the hospital has taken corrective action and would not be cited for the incident.

In a statement released Tuesday, the hospital's owner, Park Nicollet Health Services, said it took full responsibility for the "tragic medical error" and cooperated fully with the investigation. "We work continuously to eliminate errors and will not rest until we reduce them to zero," the statement said

Maura Lerner • 612-673-7384

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