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Kidney error report reveals serious failures
[Posted: Thu 23/10/2008 by Niall Hunter, Editor www.irishhealth.com]
A consultant surgeon at Our Lady's Children's Hospital in Crumlin incorrectly recommended that a child patient at the hospital needed its healthy left-sided kidney removed, when the poorly-functioning right kidney should have been removed, according to a report out today.
The independent review report into the removal of a wrong kidney from a child attending the hospital in spring 2008 says a patient with a poorly-functioning right kidney was incorrectly listed by a consultant general surgeon for a left-sided nephrectomy (kidney removal), following attendance in outpatients.
The removal of the wrong kidney was subsequently carried out by a specialist surgical registrar at the hospital who had not seen the patient previously.
The hospital admitted today that the family of the child had raised concerns about their child's surgery on a number of occasions, up to and including the time of handover to theatre. It said it did not fully address these concerns and the hospital takes full responsibility for the error.
The report indicates that a major error in x-ray reporting some years previous to the surgery which remained uncorrected was a significant contributory factor to the subsequent surgical error.
The report outlines a number of significant system failures which led to the wrong kidney removal, and recommends improvements in practices at Crumlin hospital.
The contributory factors to the error listed included that an incorrect x-ray report from six years earlier had not been corrected, lack of multidisciplinary discussion of the operation, junior doctor hours and workload, flaws in x-ray reporting procedures and the lack of a operation site-marking policy on patients before procedures.
The hospital said today it has introduced a correct site surgery policy which addressed a number of the recommendations made in the report.
One of the report's key recommendations is that staff should not rely on written imaging reports or the contents of medical records as a substitute for actual x-ray images, and that imaging should be physically present at all points in the patient's journey where a doctor is to take formal responsibility for site-marking and in theatres.
The report found that the child patient had an x-ray six years previously that showed a malfunction in the right ureter, while the formal radiology report stated that the malfunction was on the left side.
This report, the review found, appears to have formed the basis for the error in the medical records that there was a left-sided abnormality, although the correct right-sided problem was also documented.
It says subsequent radiology studies on the child all showed that the patient had a right-sided abnormality, but the x-ray discrepancy was not noted or corrected within the radiology department or by one of the clinicians who saw the patient over the following years.
The report reveals that key reports on scans confirming that the child had a right-sided abnormality went missing from the medical records, and a report on the patient's x-rays was 'lost' for six months, the period between the tests being done and admission for surgery.
The report found that a multidisciplinary discussion between consultants, which might have further reviewed the radiology and avoided the procedure being carried out on the wrong kidney, did not take place.
It also found that the child's imaging was not reviewed during the clerking and taking of consent, during the pre-operative morning round, in response to the parents' queries about the operation side, or in theatre immediately prior to the operation.
Crumlin hospital said it took full responsibility for the error and once "apologises to the child and family most sincerely."
It said it is continuing to provide the family with support and the family has chosen to have their child cared for at Our Lady's.
The review report also reveals a 'near-miss' at the hospital seven years ago where a child patient booked to have a left-sided kidney removal had a right -sided incision made, but the error was noted at an early point in the procedure and the correct procedure was performed.
The report says in the wrong kidney removal case this year, the patient was admitted the day before surgery and the procedure was carried out the following day by a specialist registrar in paediatric surgery who had not seen the patient previously.
The report says the error was realised immediately after the healthy left kidney had been removed, but it was not possible to revascularise it (re-establish blood circulation so the kidney could be reconnected).
The report lists eight root causes of the kidney removal error:
*Delays in filing hard copy x-ray in the medical records, and lack of reference to an electronic copy.
*Patients regularly admitted to the hospital outside normal working hours.
*Radiology reports not formally sent to the ward or to theatre.
*Formal consent for a procedure generally taken by surgeons who are not competent to perform the procedure.
*The person taking consent did not normally review imaging.
*Specialist registrar hours and workload, and resulting lack of planning for cross-cover.
*The hospital had no site-marking policy for operations.
*Flaws in the operation and planning of the parallel theatre list.
The review team felt two other factors will require further analysis to reach the associated root causes, although Crumlin hospital may feel that changes in practice can be implemented at this stage, based on existing knowledge of the service.
These are, that an incorrect imaging report from six years earlier had not been identified and corrected and that there was no failsafe system to ensure that a patient having a major procedure was discussed in a multidisciplinary setting.
The report, noting the previous near-miss' incident from seven years previously, notes the lack of formal structures such as a clinical risk manager or incident database.
The review team said Crumlin should examine its incident reporting systems to make sure that there is clearer communication and accountability for following-up clinical incidents within specialty teams, including 'near-misses', which illustrate significant threats to patient safety.
It says the culture and structure of risk management in Crumlin hospital by current standards would not be adequate for an incident of this nature, with systemic implications, not to be reported and discussed more widely.
The review report recommends that the hospital review its radiology systems with a view to introducing a picture archiving and communication system to create a proper digital and near filmless process.
Recommendations also include that the hospital should implement a process for initiating formal consent in outpatients, when patients are seen by a clinician who is personally competent to do the procedure and review the imaging, which is more likely, under the present system to be available at that point.
The report says the hospital should introduce a correct site surgery policy. It says patients at hospital are generally admitted to the ward by surgeons who are not considered competent to review imaging.
"If review of imaging is required in order to safely complete consent and site-marking procedures, the hospital should consider stipulating that a more senior surgeon is called to the ward."
The report says the hospital should ensure that risk management processes are 'embedded' within clinical teams.
It also states that that many of the clinicians interviewed for the review felt that the heavy caseload for the hospital's general surgery team considered against the numbers of paediatric surgeons in the hospital, was a root cause of this incident.
The hospital says it is committed, with the family's agreement, that the learning from this serious error can be shared to improve patient safety at Our Lady's and all other hopitals and health agencies.
The report is being circulated to the Department of Health , the HSE, HIQA and other bodies, including the Medical Council.
The review team said it had not provided a detailed chronology of events as the level of detail it necessarily contains would conflict with the family's request to keep the details of their child's care confidential.
The report is available on http://www.olchc.ie
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