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.
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?