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Oct 26, 2013
Oops: The Wrong Kidney Removed at Sharp
Don't be late and don't make a mistake......navigating the rough waters at Sharp Memorial OR. Why isn't the patient in the room? What's the hold up? What time will the patient be in the room? Has Sharp learned it's lesson.........when will the place listen to the nurses or will the focus continue to remain on the very rushy happiness of these wild, crazy and angry narcissistic surgeons. Hey, will nurses ever be able to talk or will they have to constantly regurgitate the current mantra......right, sharp is the greatest place to work in town......or whatever the latest concoction of diplomatic propaganda they have created. Now, if you don't think it and say it.........oops, your future might be in jeopardy...........copied from the UT:...............cl
SAN DIEGO — The state fined two local hospitals Thursday for preventable errors that led to one patient’s death and caused another to rely on dialysis for the rest of his life.
The California Department of Public Health fined Sharp Memorial Hospital $100,000 for an incident in which surgeons mistakenly removed a 53-year-old man’s healthy kidney. It also levied a $50,000 penalty against Alvarado Hospital for a case involving an elderly patient who fell out of bed, hit her head on the floor and died.
Sharp and Alvarado were among nine hospitals in the state that were fined a total of $775,000 on Thursday for errors that put patients in “immediate jeopardy” of serious injury or death.
Sharp HealthCare officials said they regret the surgical mistake. Dan Gross, the network’s executive vice president of hospital operations, said the patient received an apology quickly after the mix-up was discovered.
“More than anything, we have made a commitment to (him) to do everything in our power to have this not happen again,” Gross said.
The patient, Paul Kibbett of Escondido, sued Sharp and several doctors for unspecified damages on Aug. 7, 2012, alleging medical negligence and battery.
His attorney, Virginia Nelson, said the problems started on Jan. 3, 2012, at Palomar Medical Center, where Kibbett, who suffers from cerebral palsy, had a CT scan that detected a cancerous mass in his right kidney.
There was an initial scan mix-up that identified the left kidney as needing removal, but that mistake was quickly corrected, according to the state’s report on the Kibbett incident. But by the time Kibbett underwent surgery at Sharp Memorial on Jan. 19, 2012, his medical records again listed the left kidney as requiring removal.
Though Sharp Memorial policy said physicians should have the patient’s X-rays or CT scans present in the operating room before surgery begins, the lead surgeon in this procedure, according to the state, “forgot the necessary login information needed to access the images remotely.”
That surgeon, whom Kibbett identified in his lawsuit as Dr. Evan Vapnek, decided to remove the left kidney without the radiological verification, according to the state report.
Dr. Geoffrey Stiles, Sharp Memorial’s chief medical officer, said it wasn’t possible to reattach the healthy kidney. And it was still necessary to remove the cancerous right kidney. Stiles said the patient doesn’t qualify for a transplanted kidney from a donor, meaning that he will need ongoing dialysis to survive.
Kibbett’s lawsuit names Sharp, Vapnek and doctors Thomas Jones and James Roberts as defendants. Two other parties were initially listed, but have settled or are in the process of being dismissed from the suit, Nelson said.
Nelson also said Kibbett lives with his sister and legal guardian, Karen Brousseau, who declined to discuss the case Thursday.
“He and his family will live with the awful consequences of this for the rest of his life,” Nelson said.
Vapnek said in an email that Sharp provided to U-T San Diego this week: “Helping patients heal is my life’s work, and I have never felt such personal anguish as I did when we discovered the wrong kidney had been removed. I have expressed my sincere regret to the patient and the family over this tragic incident, and Sharp has been diligently providing the additional care required. With the assistance of my colleagues and the staff at Sharp, I have rededicated my practice to make every effort possible to prevent such an error from happening again.”
Gross, the Sharp operations executive, said Vapnek’s record is otherwise unblemished, adding that he has retained his operating privileges at Sharp Memorial.
Jones and Roberts didn’t respond Thursday evening to a request for comment.
The botched surgery occurred one month after a wrong-side surgery at the same hospital nearly cost a man his only healthy testicle. In August, the state fined Sharp Memorial $75,000 after a surgeon made an incision on the right side of the patient’s groin before realizing that it was the patient’s left testicle that was scheduled for removal.
In that case, state inspectors said the surgical team involved didn’t follow the hospital’s extensive procedures for properly identifying the correct side.
Stiles, the chief medical officer at Sharp Memorial, said the two cases were similar in that they involved confusion of left and right sides but differed in the exact mechanisms that allowed them to happen.
He also said additional training occurred after the testicle case — and continues to this day. No additional wrong-side surgeries have occurred since the Kibbett kidney incident, he said.
And Stiles said Sharp has strengthened enforcement of its operating procedures in the wake of the kidney mistake, making X-rays a strict requirement for certain types of surgery where there is a potential for confusion.
In the Alvarado Hospital incident, state investigators said an elderly woman who had fallen at a local skilled-nursing facility was admitted to Alvarado in early 2012. She was being monitored when she fell from her hospital bed and suffered a head wound that caused her to die the next day, they said in their report.
The state found that a nurse turned off a special alarm designed to warn hospital personnel if a fall-prone patient was trying to get out of bed. That action was taken “because the patient wanted to sit on the edge of the bed,” an activity that would frequently set off the sensitive alarm, according to the state.
Alvarado didn’t release a statement Thursday about the incident, though its report to the state said the hospital took steps to make sure its employees followed fall-risk policies and added a portable “personal alarm” device to make falls less likely.