Doctors Remove Wrong Kidney

A surgical team at Park Nicollet Heath Services in Minnesota removed the healthy kidney from a patient last week, and left behind the possibly cancerous kidney. We were going to make a dumb joke about this is why you should draw a giant X over your good body parts with a Sharpie marker before a surgery, but the mistake was made in the patient’s medical chart weeks before—the surgical team followed all proper procedures.

The error occurred in diagnosis before the surgery took place. The surgery staff followed all appropriate safety protocols, including marking the surgical site and pausing before surgery to confirm the final details.

Unfortunately, the side of the affected kidney was incorrectly identified in the medical chart several weeks before the surgery took place.

“Metro doctors remove wrong kidney” [KSTP.com] (Thanks to Lucille!)
(Photo: crucially)

Comments

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  1. Buran says:

    Some hospitals actually DO put big markings over the right spot, but if someone goofs before the markings are made, this is what you get. Aren’t they supposed to draw the markings and then triple-check though (including asking the patient, if the patient knows what’s up)?

    And I’d sure be asking why the right kidney couldn’t be reimplanted. I guess they just threw it away.

  2. timsgm1418 says:

    omg I can’t imagine this. When I had my kidney surgery in January, 3 different people came in and asked “we’re fixing the right kidney, correct?” and they drew on me with a sharpie etc. This wasn’t even to remove the kidney just to repair it. How the hell did this happen? Didn’t they talk to the patient before the surgery?

  3. Moosehawk says:

    I wonder if they’re taking it seriously.

  4. picshereplz says:

    Oops! I guess that’s what malpractice insurance is for.

  5. hills says:

    I feel badly for the patient and surgeon – neither one at fault. Who screwed up the medical chart?

  6. ribex says:

    @Buran: I would think there’s a good chance that the removed kidney was destined for further analysis of the cancer. Sliced and diced.

  7. Tux the Penguin says:

    @picshereplz: That’s exactly what it is for. As sad as this is, unfortunately this is what happens when you have humans doing the work.

  8. sleze69 says:

    I give the hospital credit for getting out in front of this and accepting responsibility.

  9. ClankBoomSteam says:

    I said it yesterday on the “Insurance Company Won’t Pay For Child’s Leukemia Treatment” thread, and I’ll say it again here: FUCK the medical industry, FUCK the surgical industry, and FUCK the pharmaceutical industry. Useless, money-hungry lackwits.

  10. dotcomrade says:

    Beginning in October, Medicare will no longer pay for eight hospital mistakes – including:
    # Urinary infection from catheter
    # Bed sores
    # Surgical object left in body
    # Air embolism
    # Giving wrong type of blood
    # Blood infection from catheter
    # Chest infection after bypass surgery
    # Hospital-caused injury

    “We think it’s a big deal,” said [K.W.], Medicare’s acting administrator. He says when the system stops paying for preventable mistakes, hospitals will stop making them.”

    Video: [www.cbsnews.com]

    Transcript:
    [www.cbsnews.com]

  11. rubberkeyhole says:

    I had a piece of bone taken out of my skull during an ear surgery, and I was given a permanent marker to put a dot on the right ear. I wanted to draw a giant arrow, but they wouldn’t let me. :o) I seem to remember my grandmother drawing “NOT THIS SIDE” on my grandfather when he had a ‘sided’ surgery as well…and the doctors thought it was hilarious.

  12. rubberkeyhole says:

    @dotcomrade: holy crap. nothing like punishing the patient for a hospital’s mistake.

  13. KJones says:

    I can hear the HMO now:

    “Sorry, you received sufficient treatment. We’re not going to cover future surgeries nor put you on an organ donor’s list. You’re on your own.”

  14. matto says:

    What, nobody blamed the patient yet?

  15. DrGirlfriend says:

    @KJones: No, the likely scenario will be that they won’t pay for this surgery because it did not treat the disease and they are not liable for a provider’s mistake.

  16. AdmiralNelson says:

    It happens. It’s unfortunate of course. All the processes in the world can’t prevent all mistakes.

  17. wndrwmn24 says:

    I know the Sharpie thing is meant to be a joke, but a few years ago, when I had kidney surgery, they handed me a marker, and made me mark the side that needed to be worked on. It was weird to do, but they got they didn’t screw it up.

  18. fhic says:

    @wndrwmn24: Not a joke at all. When I had surgery a couple of years ago, they had me mark the spot with a Sharpie the day before. A nurse checked it against my chart. And the last thing they asked me before they put me under was “touch the part we’re operating on today.”

  19. fhic says:

    Oh lovely. Hey Gawker people, the incredible disappearing comments problem is back.

  20. PirateSmurf says:

    someone pass the fava beans and chianti……

  21. samurailynn says:

    If the mistake was made weeks earlier on the patient’s chart, it is possible that the patient was told that the wrong kidney needed to be removed. In that case, even if the surgeon’s had double checked with the patient the same thing would have happened.

  22. ninabi says:

    I can’t imagine not marking before operating. When my son had a bone tumor removed from his leg, they made an X with a purple marker on his right femur despite the obvious, giant lump above his knee.

  23. TechnoDestructo says:

    @picshereplz: I guess that’s what dialysis, and if the patient is lucky, kidney transplants and a lifetime of anti-rejection drugs are for, too. (Assuming they didn’t get the good kidney back in in time) Yup, everything’s gonna be just fine!

  24. mgy says:

    Do you get pushed to the front of the organ donor line if you have this happen?

  25. Mizzle fo Shizzle says:

    At least you have 4 kidneys.

  26. henwy says:

    @ mgy:

    Nope. The waiting list dosen’t take things like that into consideration unless it affects the outcome of a transplant. They have to be blind to what caused the issue unless it’s likely to cause future issues.

  27. rochec says:

    @ClankBoomSteam:

    It will be interesting to see you come crawling back when you get sick.

    But I do agree about the insurance agencies. Most doctors are/would be willing to treat anyone, but the hospitals generally prevent it.

  28. pinkbunnyslippers says:

    Wow – so so sad. My guess is the patient didn’t know which kidney was necessarily the cancerous one…unless their symptoms were correlary with that kidney (pain on that side of the back, etc.)

    I’ve heard of this happening with back surgeries…x-rays get flipped and the wrong side of the back is operated on.

    But yes – this is what malpractice insurance is for. :)

  29. DoctorMD says:

    Horrible occurrence. A common problem is medical records and imaging are not readily available due to “privacy issues”. There is a good chance you could blame this on HIPPA.

    Beginning in October, Medicare will no longer pay for eight hospital mistakes – including:
    # Urinary infection from catheter
    # Bed sores
    # Surgical object left in body
    # Air embolism
    # Giving wrong type of blood
    # Blood infection from catheter
    # Chest infection after bypass surgery
    # Hospital-caused injury

    “We think it’s a big deal,” said [K.W.], Medicare’s acting administrator. He says when the system stops paying for preventable mistakes, hospitals will stop making them.”

    Thats funny because 1,2,6 and 7 aren’t “mistakes” in most cases. And 8 is open to abuse through interpretation.

  30. FightOnTrojans says:

    @dotcomrade: Yah, I hope there is something in there about forcing the hospital to eat the cost of their mistake and preventing them from trying to pass it on to the consumer. My memory is hazy, but I seem to recall that one of the stipulations of billing Medicare is that you can’t go after the patient for something that is disallowed (vs. denied) by Medicare. In other words, if you bill Medicare for using a widget while performing surgery X on a patient, and the cost of the widget is not reimbursed by Medicare, the provider can’t bill the patient for it. Someone more enlightened than I care to confirm whether this is true or not?

  31. DrGirlfriend says:

    Medicare does have rules in place that prevent providers from trying to collect from patients. Basically, if a patient didn’t sign paperwork saying “I am aware that this will not, or may not, be covered by Medicare”, then Medicare considers the patient was insufficiently informed about out of pocket costs and therefore you can’t bill the patient.

  32. ConsumerAdvocacy1010 says:

    I’m not a physician, but would there by ANY reasonable way of identifying a cancerous kidney before removing it? Comparing the two kidneys while operating (depending on the incision type) doesn’t seem to be very time consuming….

    I mean, at the least….”Hey, Dr. Smith, why does the cancerous kidney look healthier than the ‘healthy’ one?”

    Anyone a resident, physician, or surgeon that can answer?

    I wish the best of luck to the patient.

  33. chatterboxwriting says:

    I have had surgery 16 times and I have never been asked to point out my surgical site or let them know where they’d be operating. Good thing I still have all the right organs!

  34. rikkus256 says:

    They do this all the time in china.

  35. JeffCarr says:

    @ConsumerAdvocacy1010: I’m no surgeon, but if I was removing one kidney, I sure wouldn’t cut the person up so much that I could see both…

  36. rellog says:

    @DoctorMD: I’m guessing you didn’t read up on the study done in Michigan that reduce most nosocomial diseases out of the gate. The reason many of those issues occur is lack of proper care and hygiene.

  37. soulman901 says:

    Oh the flipped the X-Ray around. That’s what happened. Those darn Rascally Surgeons, what other neat tricks will they think up next?

  38. wesa says:

    Before I had knee surgery last week, both the Dr and I used permanent marker to put our initials on the correct knee to verify before they put me under anesthesia. If I were going to have kidney surgery, you better believe I would verify from everyone which one they were going to operate on before allowing them to put me under.

  39. MisterE says:

    @mgy:

    I am a dialysis patient and can answer this question just from my own experience. I am classified from the Veteran’s Administration as a 100% disabled veteran. I medically retired from the Navy as a result of injuries from the first Gulf War. I was exposed to toxins, chemicals, etc, etc.

    The question I always ask and could NEVER get a response to is this: Why do illegal aliens get priority over me for kidney transplants?

    I know all about UNOS, and the waiting list (I’m on it), but whenever I see an illegal alien getting a kidney before an American Citizen does, it drives me insane. The VA, the politicians, the news media are very quite on this issue.

    People have labeled me “racist” or “hateful” because of my attitude with this very issue. I don’t give a shit. I hate every one of those wetbacks who steal an organ that rightfully belongs to an American Citizen. I hate the fact that hospitals happily pay for their surgery when Americans on dialysis can’t afford their Renagel because Medicare fucks with their rates. Never mind the fact I’m a Veteran. I am American first and Americans should take care of their own first.

    SO, to answer the question: NO, he won’t be put to the head of the list because of a screw up. He’ll end up fucked like the rest of us Dialysis patients.

  40. erica.blog says:

    Fingers crossed that the “possibly cancerous” organ turns out to be definitively “not cancerous instead!

  41. magic8ball says:

    @MisterE: Please explain how/why illegal immigrants are prioritized above other patients on the organ donor waiting list.

  42. MisterE says:

    @magic8ball: This is a bit long winded, but since you asked….

    I’ll quote a couple of websites about this:

    [www.aim.org]

    “It was news to many people that non-U.S. citizens can be placed on waiting lists for transplants and get the same priority as American citizens. A spokeswoman for the United Network for Organ Sharing was quoted by the Associated Press as saying they cannot perform more than 5 percent of their transplants on noncitizens. This figure has been featured in many reports. But Transweb.org, which handles questions about organ transplants and donations, says the figure is actually ten percent. Some people may wonder why any non-citizens are entitled to this service.”

    [www.wnd.com]

    “UNOS says there’s a five-percent cap on transplants for non-resident aliens, but stresses the issue of citizenship is not a factor when getting onto the waiting list.”

    From UNOS Guidelines: [www.unos.org]

    6.2 GUIDELINES. Any member transplant center which agrees to list non-resident aliens on its Waiting List shall adhere to the following guidelines:

    6.2.1 Nondiscrimination/Organ Allocation. Selection, from the Waiting List, of non-resident alien candidates for transplantation shall be based on the same allocation policies (Section 3.0) mandated by the Board of Directors for selection of domestic candidates. Such selection shall not be influenced by favoritism or discrimination based on political influence, national origin, race, sex, religion or financial status.

    6.2.2 Transplant Centers. Transplantation of each non-resident alien should be done in a transplant center with a historical pattern of international referral and a reputation for both treatment of primary and endstage organ disease and transplantation, with regard to the particular organ(s) being transplanted.

    6.2.3 Fees. Transplantation of non-resident aliens is a humanitarian act and shall not be done for financial advantage. Transplant centers listing non-resident aliens on their Waiting Lists shall charge non-residents the same fees for service as those charged to domestic candidates and recipients.

    6.2.4 Referrals. Members shall not enter into formal contractual arrangements with foreign agencies or governments for the transplantation of non-resident aliens. OPTN members may negotiate the terms and conditions under which any individual candidate would be treated with the understanding that each candidate must be referred on a case- by-case and physician-to-physician basis.

    6.2.5 Community Participation. Each member center which lists non-resident aliens on its Waiting List should establish a mechanism for community participation and review of its candidate acceptance criteria.

    6.2.6 Training Programs. To enhance transplantation in underserved nations, it is desirable for transplant centers engaged in the transplantation of non-resident aliens to establish training programs which include transplantation training of physicians from underserved nations and educational programs designed for development of transplantation services in those underserved nations.

  43. Roundonbothends says:

    And the surgeon did not look at the x-rays of what he’d be working on? I have no medical knowledge here, but would

    – a diseased kidney show up as diseased?
    – the doctor be able to identify which side it was on from the x-ray?
    – the doctor compare the diseased organ to the non-diseased organ?

    This was a terrible error, but where was the “eyes-on” confirmation?

    And made WEEKS ago?

    That’s like nobody’s checking for typos.

  44. MARTHA__JONES says:

    @wesa: I heard of a patient who wrote “my Lawyer’s name and phone number is….” on the incorrect shoulder.

    I also heard of someone taping the surgeon’s favorite candy (a bag of m&m’s) to the correct knee/shoulder/whatever.

  45. padams89 says:

    @ConsumerAdvocacy1010: I am currently working in the OR’s at a major Pittsburgh hospital system and as such have seen similar procedures (performed correctly) multiple times. Depending on the type of cancer, the surgeon can sometimes (definitely not all cases) determine whether or not the kidney is cancerous. But the surgeon can not compare the two kidneys because they are on opposite sides of the body. Also generally getting access to the kidneys involves removing a small portion of one or more of the patient’s ribs. As you can see that is a little too invasive “just to make sure”.

  46. dualityshift says:

    @MisterE:
    Sorry to break it to you, dude, but you’ll never get a kidney because you are a guinea pig. Your government knows what they dosed you with, and want to see how long before complete organ failure and death.

    At least they can bag and tag the illegal aliens, and put them to work in areas and industries that ‘Proud Americans’ are to good to do.

    Next thing we’ll hear from you is how the Sub-prime meltdown was caused by illegal aliens.

    You are an angry man and should seek out much needed therapy.

  47. silverpie says:

    Heck, when my dad went in for an operation a while back, not only did they mark an X on that side, but wrote NO on the other!

  48. Dashrashi says:

    @MisterE: It’s very clear that you don’t need to call illegal immigrants wetbacks. Why would you do that, and then complain that people find you racist and inflammatory? It’s an offensive word, designed to offend. Don’t use it if you want people to take your opinions seriously.

  49. larkknot says:

    Where is the “Flag inappropriate commenter” button? I feel like I need one for Mr.E’s racist diatribe. While I certainly feel that veterans, having served our country, should get priority for medical procedures using limited supplies such as organ transplants, I do not feel that using racial slurs contributes to either the position held by Mr.E, to this discussion, or to any discussion on any topic.

  50. DoctorMD says:

    @rellog: I don’t know what “out of the gate is?” I do know hand washing can REDUCE the number of infections but due to antibiotic overuse hospitals are the worst sources of pathogenic bacteria and it is impossible to prevent all infections. There is no way to determine if the infection was inevitable or preventable. So screw the hospital?

    Too bad doctors and hospitals are honor-less, greedy bastards who won’t tell the illegal Medicare/Medicaid programs to go F themselves. Remember medicare is only possibe since price fixing, abuse of monopoly, rackettering, and extortion are allowed for the government. Oh and overlooking gross interference with private contracts.

  51. Kevin Cotter says:

    @ribex:
    Yes, the kidney was disected in pathology. The pathologist was the one that discovered it was a healthy kidney.

    @mgy:
    No, you don’t get pushed to the front of the donor list. The remaining kidney has cancer, and may be removed to stop the spread of cancer. The patient needs to be free of cancer for 6 months to even make it to the donor list. I’d bet dollors to dougnuts he’ll have some cancer left after the other kidney is removed; limph nodes or something like that.

    @ConsumerAdvocacy1010:
    Sometimes they can see if a part is cancerious or not prior to removal, but not always.

    I’m not a doctor, but my wife is. This should NOT have happened.


    Kevin
    [velcroman98.googlepages.com]

  52. MoCo says:

    So who made the mistake on the chart? It might have been a physician, but it might just as likely have been an $8 / hour medical assistant who was flipping burgers the day before she was hired.

    The point is that just because someone at your doctor’s office wears a lab coat, that doesn’t mean that they have any medical credentials.

  53. lovelygirl says:

    OMG. I would sue the pants and boxers off those doctors. Not that it would make the loss of my functioning liver better, but just to make a point. This reminds me of the guy who was getting a leg removed and he wrote all over that leg that that is the one to be removed and they removed the OTHER leg instead! That is so f*cked up, millions and billions of dollars cannot replace good health. They need to put this guy on the top of the liver donation list! Heck, those docs/assistants should all be tested and give their livers to the patient!!

  54. DrGirlfriend says:

    @MisterE: You may have been labeled racist and hateful because you use racial slurs. It’s inappropriate to use them, and most people don’t care to hear them. Please don’t express yourself that way here.

  55. ClankBoomSteam says:

    @rochec: Uh, I never said I wouldn’t go SEE a doctor; I’m not an idiot. I simply said “fuck them” — as in, these people are scum who take advantage of a simple human need and get rich doing so. Was that somehow unclear?

  56. bluewyvern says:

    @MisterE: One little point for you to consider — noncitizen != illegal alien. Would you deny an organ to my stepfather, currently a citizen of the UK, living here with a green card while he waits to qualify for citizenship? What about a foreign student stricken with sudden illness while here studying in the US? I sure hope France would have considered giving me a kidney if I’d needed one while I was there.

    That said, your use of slurs tends to bring down your level of discourse, as others have mentioned, so any valid points you may have wanted to bring up about the prioritizing of organ recipients are probably lost in your racist diatribe. I think you’re seeing things a little too black & white — for you it’s just Americans vs. Everyone Else, isn’t it?

  57. mikey07840 says:

    Everyone, Please be patient and understanding with MisterE.

    My experience is that people on dialysis sometimes have issues with controlling their emotions and especially their anger. I am on dialysis and find that at times I do not have control of my emotions. I get angry sometimes at the drop of the hat and say stupid hurtful things. I later find myself apologizing for what I preciously said. (And then going home to burst into tears about it.) In talking with my dialysis nurses, I am told the the dialysis often changes hormone levels abnormally and causes this.

  58. aka Cat says:

    @mikey07840: I’d be totally understanding of his ranting. Hormones aside, I assume dialysis and the need for it, is hugely stressful.

    But that doesn’t excuse the racial slur. Typing takes a little more time and thought than speaking — that word is part of his vocabulary, not something he just blurted out in a verbal tirade.

  59. silver-spork says:

    When I had a breast biopsy, the nurse gave me a Sharpie and had me draw a big X in the general area. Then both the nurse and the doctor asked before the giant needle went in the first time.

    I guess if I was going in for surgery, I would ask to have the area marked if it wasn’t offered.

  60. polyeaster says:

    LAWSUIT…

  61. IrisMR says:

    oops.

    @MisterE: Heh, you are hateful and racist. Anyway, it’s not as if they really have the priority. It’s more of an evaluation. If they deem that they have better chances than you at sustaining the new transplant, it will go to the alien.

    A human is a human and a life is a life. Get over the race and nationality factor.

  62. LUV2CattleCall says:

    @mgy:

    Nope, but they should harvest the moron who made the error on the charts. The prick probably isn’t even a blood donor.

    On a side-note, I believe we should have an organ donor “a-list.” If you’re signed up as an organ donor or can’t donate for a medical reason (i.e. AIDS), you get priority over those who are too selfish/religious/whatever to be donors.

  63. Mr_D says:

    I used to think it was odd how several medical professionals could make a mistake like this – they went to school for how many years and payed how much money?

    “It’s the one on the left, right?”
    “Right.”
    “OK.”

  64. Cycledoc says:

    This is malpractice. The problem is not the chart error but the surgeon apparently not doing his/her job. I’ve never seen a surgeon operate on a tumor without looking at X-rays,CT scans, MRI’s and such to determine the location and extent of a tumor.

    The patient is likely going to require a lifetime of dialysis or a transplant if the tumor involved kidney is removed.

    Pathetic

  65. Joafu says:

    This is an unfortunate case, and while the instant consumerist reaction is to point blame at someone, it’s hard to say who dun it. The chart was screwed up several weeks before, which would mean that the patient herself might not know the correct kidney to remove; the surgical team involved is NOT at fault, they did their job to their finest ability. Why didn’t the surgeons catch the error while they were inside? Because unless the cancer was some sort of late-staged renal cell carcinoma, it could look just like a healthy one, and they wouldn’t open up enough to get a side by side comparison.

    What can be done to right this problem? The American Way would be to sue so that malpractice premiums could increase and further drive up the price of healthcare. Medically, the cancerous kidney is still inside, and that does need to get out, but that will also mean dialysis for at least six months; the patient can’t just get a new kidney asap, she’ll have to be cancer free for at least six months, I believe another consumerist has already stated this. I’ve also seen a number of consumerists getting angry, and some of them are out of line (who mentioned removing the wrong liver? RTA!). Cripes.

  66. Dervish says:

    The only good news about this horrible mistake is that, according to the Star Tribune, the hospital voluntarily went public about it instead of letting it slip under everyone’s radar:
    [www.startribune.com]

  67. Beerad says:

    @Dervish: That IS good news. And Ben should be happy — they apparently are not “taking it seriously.” At least, not on record in the article as such.

  68. aaronk says:

    “Proper procedures” ought to include verification of which organ to remove. The medical field seems full of these horrible processes and I see little to no initiative on the part of doctors, hospitals, medical insurers, or malpractice insurers to force better processes. The doctors did what they were supposed to, but the process was broken. Process improvements such as this one are what the medical community (in large part) sorely lacks:
    Michigan Infection Checklists

  69. LVP says:

    If I ever need surgery I would like to be awake when they mark me up. Then I will also mark where the spot is. Maybe even write notes where they are not supposed to operate.

    “Wrong kidney.”

  70. Veeber says:

    @Buran: I would imagine that the patient might not even know. I’m wondering if someone looked at the x-ray backwards during the intial diagnosis and said “Your left kidney has a tumor.” Patient would think it’s the left one and everyone else would too until the kidney was cut out and no one would know until the biopsy was completed.

  71. That70sHeidi says:

    Maybe, Mr.E, you’re being bumped because you’re an ass in person too. Ever wonder what your chart might look like? Maybe your dialysis nurses, doctors, transplant authorizers all see that you’re an ass…. Who knows what they could be circulating about you! Better watch out, they might put fake dog doo in instead of a kidney if you DO ever make it to surgery.

    But I tend to agree with DualityShift… Grade A guinea pig.

  72. That70sHeidi says:

    It’s also troubling that a veteran doesn’t understand the difference between “illegal alien” and “non-US citizen” or “non-resident.”

  73. LikeYourFace says:

    @mikey07840: We should cut him slack because of the claims he makes about his military service and current health? I can’t verify that, so I’m not cutting him slack. I can say, however, that he is most definitely a racist bastard, based purely off his own statements.

  74. MisterE says:

    I take the racists comments very seriously….

  75. Woofer00 says:

    @Roundonbothends:
    – a diseased kidney show up as diseased?
    Depends of the type of failure that necessitated the surgery. Growths on the inside of an organ wouldn’t be visible even on the diseased kidney (I think).

    – the doctor be able to identify which side it was on from the x-ray?
    The surgeon typically doesn’t prep the patient for surgery. Also, x-ray interpretation is the radiologist’s specialty.

    – the doctor compare the diseased organ to the non-diseased organ?
    How many times do you want to slice the patient open? More/bigger/deeper cuts –> greater chance of infection, complications, and healing time.