By August 29, 2012 5 Comments Read More →

A Kidney Accidentally Trashed – More Questions Than Answers

Many of you have emailed me about this horribly sad story: “Toledo hospital nurse accidentally throws away healthy donor kidney during transplant surgery.”

As a blogger, I wish I could go to the “gemba” to really help investigate and find the root cause that answers the question “why did a kidney mistakenly get thrown in the trash?”

There are more answers than questions…

The hospital has suspended the transplant program for the time being. This is the equivalent to “stopping the line” when a problem cannot be resolved in a Lean factory, like Toyota.

The donated organ was supposed to be immediately transferred to the waiting patient, but at some point it was tossed out with the medical waste.

It took about an hour to locate the discarded kidney, which was by then ruined, hospital officials said.

Yikes.

At least the problem wasn’t covered up… somebody said “a mistake was made” and, rather than forcing the issue and trying to transplant the kidney anyway, potential future problems were averted… so credit should be given there. In an ultimately dysfunctional environment, somebody might have tried to use the kidney anyway, instead of consulting with the family to talk about the reality of the situation. Since another likely donor kidney would be available (from another family member?) they decided not to take any risks.

Can you imagine donating a kidney for a sibling… only to have it end up in the trash?

Two operating-room staff nurses were suspended with pay following the incident. They were identified as Melanie Lemay and Judith Moore. Both have refused to comment.

This leads to more questions:

If there’s a surgical team, why were two nurses the only ones suspended? (Update: “Third person suspended over failed kidney transplant at UTMC” — an administrator). Note, it seems rare for a manager to be disciplined when an error occurs.

Dr. Michael Rees, the UTMC transplant surgeon who removed the kidney before it was ruined, has not faced any discipline, said UTMC President Dr. Lloyd Jacobs.

If we’re suspending people, why not the surgeon?

The reason given by many, for suspending people with pay, is so they will cooperate with the investigation. The hospital says they want to understand how this occurred (process problem?) so they can prevent it in the future. So, kudos for that.

But how could a problem like this occur? Were there unusual circumstances that caused distractions? Why was there possibly no clear responsibility for who was supposed to trace and watch the kidney? Why wasn’t there a process that would prevent problems?

Aviation has learned from past catastrophes where nobody in the pilot was actually flying the plane or paying attention to the altitude. Why wasn’t somebody in the O.R. laser focused on the kidney and keeping it safe?

It will be interesting to follow what happens. Will people get fired? End up in jail? Or, will we have real improvements and prevention of future problems?

How can other hospitals learn from this mistake and the circumstances involved, so this NEVER happens again ANYWHERE?

What are your thoughts or your questions about this situation? What is your transplant center doing to make sure this never happens to another kidney or another organ?


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

5 Comments on "A Kidney Accidentally Trashed – More Questions Than Answers"

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  1. Anonymous says:

    Very sad story. Hopefully this will generate a call to action. I feel bad that our system could allow such a thing to happen. It is easy to find fault with our clinical quality. I am pretty sure there are relatively equal or worse grievous mistakes that we Lean implementers have made that have derailed improvements that might have prevented such events in our own organizations.

    • Mark Graban
      Twitter:
      says:

      Thanks for your comment. I think what’s sad isn’t the “clinical quality,” but rather the “process quality” that allowed the kidney to be throw into the trash. I’m certain everybody involved had the clinical training required (and the common sense) to know that shouldn’t have happened.

      I’m curious to hear more about what you mean by your last sentence or an anonymous example of how mistakes by Lean implementors might derail process improvement efforts, in this type of situation or others?

  2. anonymous says:

    My own organization has been working on Lean for several years. Progress has been lagging for a number of reasons, one of which was some bad direction I gave early on. In the meanwhile we haven’t made any type of improvement in reducing many types of patient harm and most care processes are status quo. Better direction on my part could have resulted in more processes being improved and presumably less patient harm. I haven’t been suspended with pay. I think the lessons are around improving the process we use to improve processes. I am very grateful to learn from those that have acknowledged their failures in implementing Lean. I think John Toussaint, Pat Gabow, Gary Kaplan, and others never talk about Lean without talking about the urgency of improving patient safety and/or improving the human condition. If we lose sight of that then Lean becomes much less inspirational and more about a better way to run a business.

  3. anonymous says:

    BTW, the bad direction was to move on without addressing and fully understanding specific leadership roles and responsibilities.

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