Doctor disciplined for removing wrong kidney

[MasterBlaster]

MINNEAPOLIS – A urologist has been indefinitely barred from inpatient surgery for removing the wrong kidney of one patient and taking a biopsy from another's patient's pancreas instead of a kidney. Dr. Erol Uke has signed the disciplinary ruling from the Minnesota Board of Medical Practice, agreeing that his actions justify the board's discipline.
The ruling said Uke could regain surgical privileges if the board later determines he's competent to do so.
The Star Tribune reported the ruling did not say where the errors happened, just that Uke removed the wrong kidney in March 2008 and performed the erroneous biopsy about four months later.
Uke declined comment when reached at home by The Associated Press.

 

[Rich_by_the_Bay]

And some people laughed when they learned we were making the patients sign their legs, arms, abdomen, etc. with marker before surgery to reduce the risk of wrong-site surgery. It is surprising how often that used to occur and rarely still does. Hard to imagine.

 

[segfault]

It's also surprising how infrequently doctors are disciplined...

 

[WhoDaresWins]

Amazing that something like this could happen these days with all the checks and double-checks in place. For any kind of surgery you get asked about a half a dozen times by various support staff, nurses, anesthetists, the surgeon, etc. what you are having done, very specifically, and yes, the final thing is the surgeon consults with you and marks on your body exactly what is being done after consultation with you.

 

[Rich_by_the_Bay]

It's also surprising how infrequently doctors are disciplined...

Every month I get a virtual newsletter from the state listing dozens of disciplinary actions ranging from minor to major. Same in all 4 states in which I have practiced over my career.

 

[Amethyst]

And some people laughed when they learned we were making the patients sign their legs, arms, abdomen, etc. with marker before surgery to reduce the risk of wrong-site surgery. It is surprising how often that used to occur and rarely still does. Hard to imagine.

When carpenters work on a house, they make all kinds of marks everywhere to guide their cutting and nailing. Given how much more critical it is for surgeons to be accurate, I don't see anything odd about surgeons making guiding marks on their patients.

Not being a surgeon, I can only imagine how fatiguing it must be to do such challenging, complicated work, with all the different body types out there, especially while standing on one's feet all day.

Amethyst

 

[HFWR]

And some people laughed when they learned we were making the patients sign their legs, arms, abdomen, etc. with marker before surgery to reduce the risk of wrong-site surgery. It is surprising how often that used to occur and rarely still does. Hard to imagine.

"Your sex change operation was successful!"

 

[Meadbh]

Here's an article you might like to read:

Wrong-Site Surgery: A Preventable Medical Error -- Patient Safety and Quality -- NCBI Bookshelf

It shows that the reports are actually increasing since it became mandatory to report it. Estimates are variable but one study suggests that operating on the wrong part of the body may occur once in ~28,000 cases. Even so, once is too much. There are really no excuses for not checking and double checking.

There's even one hospital where this seems to happen a lot (and which Forum members should probably avoid)...

Hospital fined $150,000 in wrong-site surgery - Health care- msnbc.com

 

[Nords]

And some people laughed when they learned we were making the patients sign their legs, arms, abdomen, etc. with marker before surgery to reduce the risk of wrong-site surgery. It is surprising how often that used to occur and rarely still does. Hard to imagine.

"Now, Doc, tell me again which one I'm autographing-- the one I want to keep, or the one that I'm giving away?"

 

[mn54]

MINNEAPOLIS – A urologist has been indefinitely barred from inpatient surgery for removing the wrong kidney of one patient and taking a biopsy from another's patient's pancreas instead of a kidney. Dr. Erol Uke has signed the disciplinary ruling from the Minnesota Board of Medical Practice, agreeing that his actions justify the board's discipline.
The ruling said Uke could regain surgical privileges if the board later determines he's competent to do so.
The Star Tribune reported the ruling did not say where the errors happened, just that Uke removed the wrong kidney in March 2008 and performed the erroneous biopsy about four months later.
Uke declined comment when reached at home by The Associated Press.

The operation with the wrong kidney happened at methodist hospital in st. louis park, a suburb of mpls. The hospital admitted the error right away and took steps to prevent it from happening again.

 

[wasgotfire]

I had the cartilage in my shoulder repaired in 2004. After I had my IV, changed, had something to take the edge off, and shaved my shoulder the doc drew the “cut line”, a few words describing what they were doing, and he singed it. The anesthesiologist also quizzed me about what they were doing and singed my shoulder. When I got into the OR the RN wanted to know what I was getting operated on and how I messed it up. Right after that stuff got blurry, I had a mask on my face, the room kept spinning, and they kept telling me to do stuff but don’t remember what it was (I think I was a bit drugged).

I woke up sick to my stomach in a different room and the nurses weren’t as cute any more. After about 2 hours they had as much as they could of me and kicked me out the door.

 

[TromboneAl]

I'm not at all surprised that this happens, with all the millions of surgeries that occur. I'm the kind of person that would "My right knee has been bothering me. No wait, it's the left knee."

 

[M Paquette]

This is another one of those horrible, but recurring issues that could be addressed by the humble checklist. There would be a checklist item to mark and sign the surgical site in advance, just as wasgotfire's surgeon and anesthesiologist did.

It's nice to see that Methodist Hospital in St. Louis Park took corrective action. Now if only a few thousand other hospitals would...

The problem with checklists as a voluntary mechanism is that there will always be someone who insists that they are far too well trained and highly skilled to bother with such trivia. I suspect that there would need to be the medical equivalent of an Admiral Rickover to force compliance.

 

[Orchidflower]

OMG! The same exact thing happened to my Uncle with his kidney in Chicago! The family wanted him to sue, but he wouldn't do it as the physician was his "friend." I'm estimating the year was about 2001, so that was pretty recent.
Because of his experience, if I were to have something "done," I'd insist they mark me up with Magic Markers to make doubly-sure they took out/off the right thing.

 

[DblDoc]

This is another one of those horrible, but recurring issues that could be addressed by the humble checklist. There would be a checklist item to mark and sign the surgical site in advance, just as wasgotfire's surgeon and anesthesiologist did.

It's nice to see that Methodist Hospital in St. Louis Park took corrective action. Now if only a few thousand other hospitals would...

The problem with checklists as a voluntary mechanism is that there will always be someone who insists that they are far too well trained and highly skilled to bother with such trivia. I suspect that there would need to be the medical equivalent of an Admiral Rickover to force compliance.

It is highly likely there was a "checklist" system in place that was actively violated by the Surgeon. That is why he is being disciplined.

DD

 

[Bestwifeever]

I have to have surgery on my knee in the near future. I'd mark my knee up but with my luck I'd either mark the wrong knee (I'm directionally impaired ) or the marker would be toxic.

 

[Alan]

I've had surgery 5 times and they always marked the site clearly and asked multiple times, but these were all external sites (shoulders (2), knee, back, toe). I imagine it is harder for internal organs so you really do have to trust that the surgeon can remember what he is doing.

 

[Rich_by_the_Bay]

I have to have surgery on my knee in the near future. I'd mark my knee up but with my luck I'd either mark the wrong knee (I'm directionally impaired ) or the marker would be toxic.

If you think about it, your humorous version shows that it's not as easy as just "using a checklist." For example, in the absence of a careful policy, a surgeon might but an X on the leg to be amputated. But the nurse or anesthesiologist who drapes the patient might interpret that X as "do NOT operate here" (maybe assuming that a check mark would be used if it were the correct leg).

Then they cover everything except the leg in the area of the incision. Surgeon comes in and asks "Did someone confirm the skin markers" to which the nurse answers "yes." Bye bye good leg.

I know, it's a stretch but people of good intention commit such errors unless the system makes it almost impossible to do so. Another issue: when you have used a given checklist 1000 times, it is hard to avoid not paying close attention to it.

Aviation and nuclear power have among the best error prevention, detection and correction systems in the country. Medicine is making rapid gains but has a long way to go.

 

[Moemg]

One of the problems is the incredible workload on the operating team . I spent almost thirty tears in Operating Rooms assisting in major ( hip ,knee replacements , lung removals , craniotomy ,etc .). You are expected to clean up from the last operation and be ready for the next operation in twenty minutes . That involves non stop work . Huge equipment needs to be moved and tested . Supplies Have be prepared , Instruments need to be counted and Patients have to be checked in and ready to go . All the while surgeons are breathing down your neck to go faster and the hospital wants you to go faster with less help so is it any wonder these things happen. If one of these TV shows honestly showed what went on in an OR and how many staff they use to do this work America would be shocked . I know this is no excuse for the mistake that happened but to me with all the cut backs in hospitals I'm amazed that more mistakes do not happen .

 

[mn54]

One of the problems is the incredible workload on the operating team . I spent almost thirty tears in Operating Rooms assisting in major ( hip ,knee replacements , lung removals , craniotomy ,etc .). You are expected to clean up from the last operation and be ready for the next operation in twenty minutes . That involves non stop work . Huge equipment needs to be moved and tested . Supplies Have be prepared , Instruments need to be counted and Patients have to be checked in and ready to go . All the while surgeons are breathing down your neck to go faster and the hospital wants you to go faster with less help so is it any wonder these things happen. If one of these TV shows honestly showed what went on in an OR and how many staff they use to do this work America would be shocked . I know this is no excuse for the mistake that happened but to me with all the cut backs in hospitals I'm amazed that more mistakes do not happen .

Well that settles it for me. I refuse to go to any OR and have any surgery done from now on.

 

[ERD50]

If you think about it, your humorous version shows that it's not as easy as just "using a checklist."

....

I know, it's a stretch but people of good intention commit such errors unless the system makes it almost impossible to do so. Another issue: when you have used a given checklist 1000 times, it is hard to avoid not paying close attention to it.

Aviation and nuclear power have among the best error prevention, detection and correction systems in the country. Medicine is making rapid gains but has a long way to go.

I think the medical profession has a lot to learn, aviation and nuclear are probably good places to learn from. Even the thought that there would not be some long established SOP on "X marks the spot" or "X marks - do not touch" is an indication of systemic problems. More to the point, "X" is a bad way to do it, "X" does not communicate a specific, non-ambiguous action, it requires a "decoder ring" to know what it means. Not good.

You're right, a checklist alone gets stale pretty quick, you need a checklist and checks-balances on that checklist that keeps people involved. Such as one person reading the list, another responding with data, not just "check, check, check, check...." (ooops, was that 4 'checks' or 5 'checks', ....whatever). It's tougher to get complacent with "Oxygen? - Oxygen reading 4.5"; " BP? - BP reading 110/85"; "Marking on limb to amputate? - 'cut here' marked on right arm to amputate at elbow, "save' marked on left arm", etc. ( fill in with much more official sounding medical lingo ).

We used closed-loop-checks-balances for things far less important than someone's organ or limb. I've been shocked at how lax the medical industry is on these things. A friend of ours is a pharmacist. I asked her about how the heck they know what to do with that scribble on an Rx pad. She said something causal like "Oh, there are typical meds and typical dosages, we know you wouldn't get 100mG of a certain medicine - must be 10mG because that's typical. If something looked out of the ordinary we would call the Doc". It was just unfathomable to me that there wouldn't be some formal checks-balances in something like that.

Now, when you present engineers with a checklist and checks-balances, some of them get offended. "I know what I'm doing - that's what you pay me for", some will say. They feel like you don't trust them, or they are being treated like children. I suspect this is an issue with a lot of Doctors. You have to get them to understand that it's not about "them", it's about having a system in place that can be relied on to limit errors. And if an error does occur, having a system in place means you have something to improve. Without a system, how do you make it 'better'? It's really hit-or-miss.

One of the problems is the incredible workload on the operating team.

...

I know this is no excuse for the mistake that happened but to me with all the cut backs in hospitals I'm amazed that more mistakes do not happen .

I don't doubt it, but not many people claim they have a lot of extra time for extra checks-balances. But as I said above, w/o it, not only will 'stuff happen', but it won't get better, because there is no basis to build upon. We often found that well designed checks-balances reduced our workload, we knew who was doing what, knew if it was done, and didn't waste time doing things twice or waiting for something we thought was done already. Things ran smoother, with less stress, which means you apply more mental power to the things that really need it. You might catch something else that you may have missed because you were distracted by something that wasn't ready because you didn't have a check-list. It's not always a time adder. It can be a pain getting it started, but once you have a good system in place, you wonder how you lived w/o it. That was my experience. Checklists and checks-balances designed to help you get the job done, not just to say you have a checklist.

-ERD50

 

[M Paquette]

Now, when you present engineers with a checklist and checks-balances, some of them get offended. "I know what I'm doing - that's what you pay me for", some will say. They feel like you don't trust them, or they are being treated like children. I suspect this is an issue with a lot of Doctors. You have to get them to understand that it's not about "them", it's about having a system in place that can be relied on to limit errors. And if an error does occur, having a system in place means you have something to improve. Without a system, how do you make it 'better'? It's really hit-or-miss.

Sad, but true. There's a certain amount of personal self-awareness needed to accept mundane things like checklists. There has to be an awareness that one is not actually infallible, and a willingness to accept that an externally imposed mechanism can improve one's own results.

That can be a hard thing for some folks.

 

[Moemg]

There are a lot of checklists in place in an Operating Room . The patient is identified and asked by the nurse , the anesthesiologist and the physician what surgery they are having and the patient points to the area . The area is then marked by the physician . When the patient gets to the OR they are again asked and before surgery starts all the team members need to be in agreement with what procedure is signed for and this is all carefully documented on checklists .

 

[Texas Proud]

There are a lot of checklists in place in an Operating Room . The patient is identified and asked by the nurse , the anesthesiologist and the physician what surgery they are having and the patient points to the area . The area is then marked by the physician . When the patient gets to the OR they are again asked and before surgery starts all the team members need to be in agreement with what procedure is signed for and this is all carefully documented on checklists .

If that is the case in all locations... then why are there so many 'failures'? Because SOMEONE in the OR should have said something when the doc started to do the wrong thing...

 

[Moemg]

If that is the case in all locations... then why are there so many 'failures'? Because SOMEONE in the OR should have said something when the doc started to do the wrong thing...

If the consent says the right side when it should have said the left side things happen .