Disciplinary records provide new details on botched kidney transplant operation at UTMC

9/26/2012

A nurse who was present when a kidney was removed, cleaned, and placed in a machine at the University of Toledo Medical Center during a transplant failed to update a fellow nurse about the happenings when she returned to the room, according to disciplinary records released today.

The records provided 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. 

The two nurses who are no longer employed by the hospital failed to follow procedures, UT President Dr. Lloyd Jacobs told The Blade.

"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.

According to disciplinary records released by UTMC today, 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.

Joseph Klep, interim director of labor/employee relations at UT, said in his recommendation to fire Ms. Lemay that she 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 OR 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 OR."

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, the former Medical College of Ohio, voluntarily suspended its live kidney donor program after the incident, although Dr. Jacobs said Wednesday that he's confident it will be reinstated in the next few weeks.

Other records released to The Blade indicate the hospital instituted two new 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 only may take breaks during a procedure 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.

Contact Jennifer Feehan at: jfeehan@theblade or 419-724-6129.