Tennessee, US – 6th August, 2019: Two Vanderbilt University Medical Center doctors said under oath they mistakenly implanted a medical device in the wrong kidney in 2017 and are now being investigated by state health officials.
One of the doctors said that a malfunctioning electronic whiteboard contributed to the error.
Dr. Kelvin Moses, a Vanderbilt assistant professor of urology, and Dr. Elizabeth Green, a urology resident, both admitted to the error during depositions last month in a lawsuit filed by Carla Miller, the Jackson woman who received the botched procedure.
Miller sued Vanderbilt for more than $20 million in March, then died two months later of heart problems, attorney Brian Manookian said. Miller's family is continuing the lawsuit and plans to argue that kidney issues contributed to her death.
“Her kids just take her place in terms of who brings the suit,” Manookian said. “When somebody passes away, the suit is maintained by their next of kin, and in this case, that's her children."
Wrong-site surgeries like this one are among the rarest mistakes in modern medicine and known broadly as “never events” because they should never occur if hospitals follow proper procedures. The U.S. Department of Health and Human Services says these "vivid and terrifying errors" occur once in every 112,000 surgeries and at individual hospitals maybe once every five or 10 years.
Vanderbilt spokesman John Howser said the hospital conducted an analysis of Miller’s procedure immediately after the wrong-site error was discovered, then implemented “corrective steps to ensure a similar error would not occur.”
“VUMC has a robust quality improvement process and adheres to the national standards for surgical timeout procedures and has state-of-the art processes and equipment to aid our physicians and to avoid error as much as possible,” Howser said. “Human error sometimes occurs despite the best of intentions.”
Despite the error, Miller continued her treatment at Vanderbilt, Howser said. There is “no evidence” the mistake had any impact on her health or contributed to her death, he said.
Stent implanted in right kidney, not left
Miller was hospitalized at Vanderbilt in November 2017 due to pain in her side and a fever. Doctors decided to implant a mesh tube called a stent into her urinary system.
The stent was supposed to be threaded from Miller's urethra through her urinary system and into her left kidney, but doctors instead implanted the tube in the wrong half of her body and into her right kidney, according to the lawsuit.
Moses said during his deposition that he reviewed the plan for the procedure beforehand but then incorrectly remembered the details and didn't double check his recollection.
"It was an inadvertent mistake," Moses said. "I don't have an explanation for it."
Green provided a more detailed explanation. During her deposition, Green said the error originated with her when she initially announced the wrong side of Miller's body as the procedure site before the operation began.
Normally, the surgery team would have checked the site against an electronic whiteboard that displays a checklist of patient information. However, Green said the whiteboard was not working for an unknown reason, so the stent procedure continued in the wrong spot.
The mistake was discovered the following morning by another Vanderbilt resident, Moses said during his deposition. Moses said he then apologized to Miller and took "responsibility" for the procedure, saying he was the "source" of the error. Moses said he did not disclose that other members of the surgical team contributed to the mistake.
As a result of the error, Miller needed a second procedure to remove the stent and place it on the correct side of her body. Another attorney for Miller, Afsoon Hagh, said in March that Miller suffered damage to her urinary system that required her to need dialysis for the rest of her life.
Both Moses and Green said in depositions they have been interviewed about the surgery as part of an investigation by the Tennessee Department of Health, which is responsible for discipline of medical professionals throughout the state.
Source: https://www.al-monitor.com/pulse/originals/2019/08/palestine-west-bank-hospitals-law-protect-doctors.html