UTMC review finds nurse failed to follow procedures in botched kidney transplant
9/27/2012A Texas transplant surgeon hired by the University of Toledo Medical Center to review its living-donor kidney transplant program after a viable kidney was thrown into the trash concluded the debacle was the “baffling” act of a nurse who didn’t follow procedures.
“Our review identified no systemic process or team culture which could have indicated the program was at risk of experiencing the noted discard,” wrote Dr. Marlon Levy, surgical director, transplantation, at Baylor All Saints Medical Center in Fort Worth.
“It does indeed seem to be an act of an experienced nurse who did not follow procedures or standard operating-room behavior in her actions, and who was not able to explain her actions. ... Her actions were indeed baffling.”
RELATED CONTENT:
Dr. Levy’s six-page report, which was obtained by The Blade on Wednesday, revealed new details about the Aug. 10 surgery in which a kidney was removed from a Toledo man at the hospital and was supposed to be transplanted into his sister.
The organ was inadvertently discarded with medical waste by a part-time nurse, Judith Moore, who resigned Sept. 10. On Monday, UTMC said it had fired Melanie Lemay, a 30-year employee and full-time registered nurse who was the "RN circulator" in the operating room at the time of the incident.
UTMC President Lloyd Jacobs said Wednesday he agreed with Dr. Levy's conclusions about the incident, but he stressed the mistake represented "outlier" behavior, and that UTMC, the former Medical College of Ohio, has a long-standing culture of safety.
"The important thing is we have procedures and checklists and policies and educational efforts in place to try to limit human errors and ameliorate the impact of human error," Dr. Jacobs said.
The two nurses who are no longer employed by the hospital failed to follow just such procedures, he said.
"We did not terminate them or allow them to retire in lieu of termination because they made a mistake," Dr. Jacobs said. "We terminated them because they violated policy."
Dr. Michael Rees, the transplant surgeon who had removed the donor patient's kidney, lost his director's title, but otherwise has not faced disciplinary action and remains a surgeon at the medical center.
"As far as we are able to ascertain, the surgeon did everything absolutely correctly," Dr. Jacobs said, adding that the idea the surgeon is responsible for everything that happens in the operating room is no longer an accurate one. "Surgeons frequently have tunnel vision because of goggles and visual aids. The circulator nurse is supposed to have surveillance of the entire room."
According to disciplinary records released by UTMC on Wednesday, Ms. Lemay had relieved Ms. Moore in the operating room while Ms. Moore went on a lunch break. During that time, the patient's kidney was removed, cleaned, and placed in a slush machine — an apparatus that keeps the organ cool until it is transplanted. When Ms. Moore returned from her break, Ms. Lemay did not update her, the reports state, and Ms. Moore proceeded to remove the contents of the slush machine and flush them down a hopper where liquid waste is flushed into the hospital's waste-collecting system.
"The missing kidney was discovered when the recovery surgeon looked up from the operative field, noticed the empty ice machine, and asked as to the kidney's whereabouts," Dr. Levy wrote in his report.
"The discard was discovered within a short period of time, but two and a half hours had elapsed until the kidney could be recovered from the waste system."
The kidney ultimately was discarded after "extensive consultation amongst clinical leadership of the program and the family, including the donor and recipient. ... The recipient, having been anesthetized but not incised, had been awakened and informed of the events," his report stated.
Joseph Klep, interim director of labor/employee relations at UT, said in his recommendation to fire Ms. Lemay that she had failed to follow several procedures. She did not log off Ms. Moore after she relieved her nor did she log in Ms. Moore's return.
She neglected her duty, Mr. Klep wrote, because she did not update Ms. Moore when she returned.
"From the vantage point of Ms. Lemay in the [operating room] suite, she could have not helped but notice that Nurse Moore was removing items prior to the closing of the patient," Mr. Klep said.
"As circulating nurse, it was Ms. Lemay's duty to stop or halt Ms. Moore from taking items out of the O.R.."
Dr. Levy, in his report, did not single out Ms. Lemay, but said he was "baffled that no other team member saw [Ms. Moore] dismantle the slush machine and remove the contents from the room."
Through her union, AFSCME Local 2415, Ms. Lemay on Monday filed a grievance contesting her termination. The grievance accuses UTMC of "publicly making an example of Ms. Lemay and ... attempting to take the public eye off of the University of Toledo Medical Center's management's responsibility in this case. Ms. Lemay was not the only individual in the O.R. suite, and was not the primary authority figure over the organ that was removed."
UTMC voluntarily suspended its live-donor kidney transplant program after the incident, although Dr. Jacobs said on Wednesday that he's confident it will be reinstated in the next few weeks.
Records released to The Blade indicate the hospital instituted two policies in the weeks after the botched transplant. One states that all contents of the operating room are to remain there "until the patient physically leaves the operating room following a surgical procedure."
The other says staff members may take breaks during a procedure only after they have consulted with the attending surgeon.
New, higher-visibility donor kidney containers also are to be used during procedures along with donor kidney idenitifer signs that are to placed on the slush machine when a kidney is inside.
Also Wednesday, Dr. Jacobs confirmed reports that a number of UTMC employees as well as community members have come forward to offer to be screened as possible kidney donors in the aftermath of the incident.
However, kidney donations cannot be made to a particular patient; they must follow the nationwide registry for patients, experts have said.
"I can't tell you too much detail, but every cloud has a silver lining or two, and this is one silver lining for this cloud," he said.
Officials have declined to comment on the status of the woman who was to receive her brother's kidney, citing privacy laws and the family's desire for privacy.
Dr. Jacobs said he was confident she would receive a kidney through the chain of kidney donations pioneered by Dr. Rees and his Alliance for Paired Donation Inc.
"Ultimately along the chain, this particular patient will receive a kidney," he said.
Contact Jennifer Feehan at: jfeehan@theblade or 419-724-6129.