I came across this pretty astounding surgical error: a Toledo area nurse tossed out a healthy kidney during a transplant surgery. Read more here: http://www.toledoblade.com/Medical/2012/08/24/UTMC-nurse-tossed-out-kidney-ruined-it.html. This kind of error, seemingly unbelievable, raises a number of interesting considerations.
The article proclaims that such an error is rare. I take issue with that. Surgical errors are all too common. I have personally seen many clear-cut errors, such as where a sponge, towel or other instrument is left inside a patient, despite systems in place to account for all surgical implements. On one occasion, I represented a gentlemen who had an 18-inch retractor blade left inside of him following a surgery. While I agree that “people make mistakes,” that does not excuse such mistakes. When these surgical errors occur, it is important to hold physicians, nurses and hospitals fully accountable so that the patient is compensated and the mistake is punished.
But there are many other surgical errors that, unlike the above-described retained foreign object cases, are not as obvious to the lay observer. Surgeons often like to argue that surgical complications are “known and accepted,” meaning that they can occur even in the best of hands. The so-called “known and accepted complication” defense has been institutionalized as an antidote to medical malpractice claims arising out of surgical misadventures. In truth, many of these complications are the result of poor technique, inadequate training, unnecessary surgery, rushing and carelessness. However, since the surgeon is the only witness to his/her own mistake, the op report gets written up in a benign fashion and the patient bears all of the consequences of the injury.
What is rare in the Toledo case is that the healthcare providers actually owned up to the mistake. Despite having practiced as a malpractice attorney for many years, I have only had one occasion where a physician admitted making a mistake. One. In the face of a worsening medical negligence epidemic, and the many errors that I have personally investigated, it is deeply troubling that healthcare providers’ default position is abject denial. This lack of honesty and integrity in the medical field is, in part, a product of a culture gone awry.
I have the privilege of working with some of the finest doctors in the country and count a number of doctors and nurses as being among my closest friends and family. My respect for their training, intellect and perseverance is heartfelt and profound. But they work in a culture where secrecy is the rule of the day. Incompetent practitioners and dangerous practices are protected in this culture. Improper influence from pharmaceutical companies, device manufacturers and ever-expanding hospital systems is allowed flourish in this culture.
So, is the mistaken disposal of a transplantable kidney a rare event or part of a bigger problem like poor nurse training and hiring practices or understaffing? We will never know. After the apologies and press releases, it will be business as usual in Toledo’s hospitals.