Losing track

A tragically bungled procedure at the University of Toledo Medical Center last month destroyed a kidney removed from a living donor for transplantation in his critically ill sister. A just-released review of the misadventure identifies numerous errors of omission and commission by hospital staff.

Before UTMC is allowed to resume its live kidney transplant program, university and hospital officials must show, not merely assert, that it has improved its policies and practices so that such mistakes will not -- and cannot -- recur.

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The report, prepared by the Ohio Department of Health for the U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services, was made public this week. It offers the clearest description yet available of how a surgical nurse -- who has since resigned -- inadvertently discarded the just-removed kidney without the chief surgeon or any other operating-room personnel noticing or stopping her.

The errors appear to have been violations not of complicated medical procedures, but rather of common-sense norms of attention and communication. The report says the nurse was out of the operating room while the kidney was removed, wrapped in a sponge, and placed in a slush machine to keep it cold.

She returned and emptied the contents of the machine -- usually the task of a surgical technician, although UTMC appears to lack a formal policy about that -- without talking to her colleagues. She said she did not realize the kidney still was in the machine, believing the organ had been taken to the recipient's room.

Evidently nobody saw her leave, even though she carried a large bag past several colleagues. She took what she thought was medical waste "into a dirty utility room and flushed [the kidney] down a hopper," the report says.

The report notes there was no written record of where the kidney was placed in the operating room after it was removed -- not the first time that UTMC kidney transplant procedures were inadequately documented, it says. Another hospital policy says nothing should be taken from an operating room before the patient leaves, but it was not followed.

The report concludes that the hospital "failed to ensure adequate supervision and communication [were] provided in the operating room, and failed to have adequate policies in place to achieve a high standard of patient care."

We continue to believe that UT and its hospital would benefit from a full examination of the incident by an ad hoc panel of prominent transplant surgeons from several outside institutions. An independent review would provide greater public credibility than a self-investigation.

The lead surgeon has maintained silence about the matter. Meanwhile, UT has not released a report it commissioned by a Texas transplant surgeon on the botched procedure and its transplant practices in general. That report is clearly a public record; disseminating it would suggest at least a degree of transparency.

Surgeon and medical professor Atul Gawande's recent book The Checklist Manifesto: How to Get Things Right explains how following a simple safety checklist can prevent disastrous medical errors -- or, for that matter, airplane crashes. UTMC may want to make Dr. Gawande's book required reading for its employees, and its executives.