Nurse, UTMC policies get blame in botched surgery

Nurse didn't realize she took, discarded kidney in slush during Ohio transplant, report says

9/24/2012

An Ohio Department of Health report released on Monday details communication errors and a failure to follow policies at the University of Toledo Medical Center that led to a botched kidney surgery last month.

The 13-page report gives the most detail yet in how a usable kidney was discarded Aug. 10 before it could be transplanted into the donor’s sister. The hospital voluntarily suspended its live-kidney donor program after the incident, and has disciplined several employees, including two nurses involved in the surgery.

Judith Moore, a part-time nurse, resigned Sept. 10 after her suspension, and university officials said Monday that Melanie Lemay, a full-time nurse, has been fired from UTMC, the former Medical College of Ohio.

According to the report, a nurse went on break for 50 minutes during the Aug. 10 transplant and was relieved by another nurse. While the first nurse was away, the kidney was removed from the patient, wrapped in a lap sponge, and placed in a “slush machine.” The second nurse, a scrub technician, and two physicians were in the room when the kidney was removed and knew of its location.

The first nurse returned to the operating room and removed the contents of the slush machine. She didn’t ask anyone what had happened while she was away, and no one told her, according to the report.

The nurse carried the slush machine’s contents, which included the kidney, “down a hall, into a dirty utility room, and flushed [it] down a hopper,” the report states. The nurse told investigators that she thought the kidney was in the recipient's room, "because that is what usually happens."

The second nurse said she believes she was doing electronic charting when the kidney was removed from the room, according to the report. The scrub technician was responsible for the slush machine, but did not notice the nurse remove its contents, the report states.

A source familiar with the incident said Ms. Moore was the nurse who threw the kidney away.

There was no documentation indicating where the kidney was placed after it was removed from the patient. The health department cites two other occasions during transplants at UTMC that involved scarce reporting of the time or location of the kidneys.

In a May incident, documentation only showed when a kidney was removed, and not where it was placed. In a July case where a patient was receiving a kidney, there was no documentation that showed when the kidney entered the room, the report shows.

Health department officials conducted interviews about the botched transplant in late August, and forwarded the report to UT officials late last week, according to a department spokesman. A UT spokesman said the university had no comment at this time.

Calls to Dr. Jeffrey Gold, chancellor and vice president for biosciences and health affairs at UTMC, and Larry Burns, UT's vice president of external affairs, were not returned on Monday.

The transplant was led by Dr. Michael Rees. According to the report, the donor patient was being closed up when staff in the room realized the kidney was not in the slush machine.

Both Dr. Rees and an anesthesia resident who was in the room told health department investigators that they didn't notice the nurse remove the slush machine. An administrative staff member says in the report the hospital did not know how the nurse could leave the room with a 13-gallon bag without four other people noticing. She would have had to walk half of the room's perimeter, past the second nurse and the nurse technician, and out the room's only exit door, according to the report.

Dr. Rees, who was surgical director of renal transplantation and assistant director of the transplantation immunology laboratories services, has temporarily lost his director title, though he is still a surgeon at the medical center. UTMC officials have said the change does not suggest that Dr. Rees did anything wrong.

Dr. Rees has not returned several calls for comment since the botched transplant.

The report cites several policies that were disregarded during the transplant, and standard procedures that weren't followed. The slush machine is usually emptied by the scrub technician or a perioperative technician, not the circulating nurse. The normal process to not remove anything from an operating room until drapes are removed from a patient was also not followed, according to the report.

Hospital policy calls for a nurse being relieved to initiate communication so that the relieving nurse is informed of what has happened in the room. That must occur as soon as the relief nurse enters the room.

Edwin Hall, administrator of surgical services, was notified Aug. 27 that he would be on "paid administrative leave" but was reinstated to his job on Sept. 14.

The Health department also notes in its report that UTMC did not properly monitor the humidity levels in its operating rooms for several months, leading to humidity levels well below where it should have been based on hospital policy.

The report was prepared by the health department for the Centers for Medicare & Medicaid Services, an agency within the U.S. Department of Health and Human Services. An Ohio Health Department spokesman said any possible further action against UTMC would be up to the federal agency.

Contact Nolan Rosenkrans at: nrosenkrans@theblade.com, or 419-724-6086.