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Subscribe to RSSA nurse who accidentally disposed of a living donor's kidney during a transplant said she didn't realize it was in chilled, protective slush that she removed from an operating room, took down a hall to a dirty utility room and "flushed down a hopper," according to a report released by health officials on Monday.
The nurse said she had been on a break when a surgeon told everyone the kidney had been put in the sterile, semi-frozen solution. That detail was in a review by the state for the federal Centers for Medicare and Medicaid Services (CMS) and obtained by The Associated Press through a records request. The transplant was Aug. 10 at the University of Toledo Medical Center.
Hospital administrative staff members interviewed on Aug. 21 hadn't determined how the nurse took the 13-gallon bag of slush, meant to extend the kidney's viability, past several members of the medical staff without them noticing a problem, the report said.
It said poor oversight and communication and insufficient policies were factors in the kidney's disposal, which prompted the voluntary, temporary suspension of the hospital's living-donor kidney transplant program and led to reviews by health officials and a consulting surgeon hired by the hospital.
The hospital, in northwest Ohio about 135 miles north of Columbus, "failed to provide adequate supervision and communication resulting in a donor's kidney being carried out of the operating room, down a hall, into a dirty utility room, and flushed down a hopper," the report stated.
The hospital has since enacted clearer policies to clarify communication between nurses who fill in for one another and to make sure nothing is removed from an operating room until the patient has been moved from it, the report said.
The surveyors determined the hospital wasn't in compliance with CMS conditions of participation for transplant and surgical services. CMS will authorize a full review of the conditions of participation for the hospital, and, if it's found out of compliance, it could be terminated from the Medicare program, CMS spokeswoman Elizabeth Surgener said in an email.
The hospital, which says it offers specialty care in areas including cardiology, cancer, surgery and kidney transplantation, also may submit a plan of correction.
A spokesman said he had no comment to provide from the hospital Monday.
The hospital hasn't said what happened to the intended kidney recipient, who was supposed to receive an organ donated by her brother. The intended recipient and her brother were released from the hospital, which didn't identify them and said it couldn't say whether she received a different kidney.
Hospital officials apologized and hired a Texas surgeon to evaluate their transplant procedures but have not released the results of that evaluation.
The medical center suspended two nurses after the incident; one was later fired, and the other resigned, the hospital said. A surgeon was stripped of his title as director of some surgical services, and a surgical services administrator put on paid leave has resumed work.
The hospital also notified 975 patients and potential organ donors and recipients that they might need to make other arrangements for services typically provided through the program under review.
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The whole story sounds strange or else has been reported inaccurately. The removed kidney would still be on the sterile field & in a sterile container, covered with sterile slush. A circulating RN is unsterile & never removes/touches anything on the sterile field without a handoff by a sterile person while the surgery is in progress. Plus,I've been part of retrieval teams, including multi-organ retrievals & have never seen 13 gallons of slush, let alone all that in a bag. A sterile trash bag? I've never seen one, has any other RN?
I'm confused by you statement "A circulating RN is unsterile & never removes/touches anything on the sterile field without a handoff by a sterile person while the surgery is in progress." Anyone that comes into an OR is suppose to be scrubbed and wear the surgical scrub gowns in case they are needed to touch something in the sterile field in case of emergencies, especially if the surgical team is handing off the specimen to that circulating nurse, she has to be scrubbed as well to receive the organ to take to the other room.
Actually the comment about the sterile trash bag is true....they do use them for bigger items such as arms and legs when they do remove them for them to go to pathology...how else would you transport an arm or a leg? a petri dish? It still has to be sterile for pathology so they can get a good diagnosis/biopsy whatever they need to do with it. if its not a sterile you have just tainted the specimen causing it to warp the results.
It's not true that anyone who comes in to an OR is scrubbed. The circulating nurse does not scrub and is not sterile. She does the paperwork and brings more supplies as needed to the sterile field. Specimens and organs leaving the sterile field stay sterile by remaining inside a sterile container, the outside of which is not sterile. While RNs most assuredly receive more training than scrub techs, the scrub tech's whole training revolves around the OR and sterile technique. I started my medical career as a scrub tech and when I went to nursing school, I was appalled at what passed for "sterile technique." The srub tech or, in some cases, scrub nurse, is responsible for everything on her field. He or she counts all the sponges and sutures and labels and keeps track of all the meds. No one but the scrub tech should be touching the sterile field. My surgeons never grabbed their own instruments or put things on my mayo stand or back table. I cannot speculate as to what happened in this case, as I was not there, and I am sure all the people involved feel absolutely awful that this happened.
Mdnatr is correct,obviously "Molly Elizabeth" has never worked in an OR. People not scrubbed-in may enter a surgery room without sterile garb,but with hair coverings & a mask. Also, large specimens such as limbs are not always sterile when sent to pathology.
mdnatr & JA-RN - Isn't it interesting ow many people who have never been in an OR know so much about it?
Maybe we should let them take over?
MollyElizabeth, are you ready for your 15 minutes of fame?
I wonder if there was an RN after the name!
Having only one, that gave me the Willies.
dialisis ain't no joke , oculd you imagine donating to a relitive and now your both with out ???//////// serious malpracktice souit here . $25,000 for the kidney then pain and suffering then goin on the "list" and all the dialisis at 3 hours per day 3 times a week . whom did not label the slush bag a GOOD kidney ??
As the parent of a kidney recipient, this horrifes me. Had this happened to us, I wonder what would they have done. At one point during our transplant, I was told the kidney was "lost". Thankfully it was located, but it was certainly a tense 10 minutes. Someone took it to it's next station on it's way to the OR and didn't sign the appropriate documentation. Having said that, she's 7 years out and doing great (thank you to her donor and his family).
holy lord
And these people are the "custodians" of our health and well being.
Anytime anything leaves an OR room it is checked in and it is checked out and it is counted-obviously, they all got lazy, especially the nurse. You don't move a container like she did full of slush and not check it first, then re-chedk it before you dump it.
I feel sorry for the person that gave up their kidney for a family member and now has one kidney while his perfectly good one was discarded like garbage.
That hospital needs a serious overhaul. Think its bad now, wait----
I don't see the problem. Doesn't the brother have another kidney to donate to her? It's not like we don't ALL have 3 of them ffs! <sarc>
I was a former Surgical Technician and when you are in an OR, the nurse is not suppose to come near the patient when the patient is open unless they are scrubbed (hence the scrub nurse, which is still just a nurse who is scrubbed for surgery and can assist....but they have surgical technicians in every hospital that are professionally trained for this). The specimen(the kidney) is placed in a container,whether its a bag or a dish, depends on the specimen and is handed off to the surgical tech who then places on the table,labels it or has a designated spot on the table (you can use a marker to write on the paper mat that is placed on the surgical table for sterility, what is to go in that area so EVERYONE can see it) and does what they need to it to have it get prepared for transport. It is then given to the nurse who then does what they need to.If both patients were being operated on duely, then the nurse would take the specimen to the other waiting surgeon in the other operating room and continue with the procedure. Obviously if they were changing shifts (which I find hard to believe because when you are in surgery, you are there til that surgery is over no matter the time frame(--hence accountability), the nurse should of minded her own business and not of assumed it was ok to remove anything. The surgeon cannot keep his/her eyes on the patient and the task at hand and pay attention to the people in the room. They don't care about the anyone except the patient. According to not only hospital policies and procedures, but when you are in nursing school/surgical technician school, you are told repeatedly you are not to remove anything from the room so its quicker at the end. Everything has to be counted for. There are checklists that we used. It seems to me the organ was being put in slush to be transported to the donor recipient which was to be done after either 1. the surgery on the donor was done and no complications were found or 2. the donor wasn't fully prepped for surgery and it needed to be "kept on ice" til the pt was ready.
I'm sorry I am tired of hearing about how bad nurses have it. Alot (not all) nurses bring problems on themselves. The majority of nurses here have Unions and they need to follow Union guidelines....and not just do things and expect not to be in trouble if they did something that isn't in their contract. If its not in your job description or within your realm of expertise...then guess what? you don't do it!!! why??BECAUSE ITS NOT YOUR JOB, YOU ARE TAKING IT AWAY FROM SOMEONE WHO SHOULD BE HELD RESPONSIBLE IF IT DOESN'T GET DONE, THAT WAY THEY ARE IN TROUBLE AND NOT YOU!!!!! They take on jobs that they have no business doing, case in point. The nurses in the OR should have some type of background in surgical procedures and not just everyday ordinary nurses. Surgery is different then taking samples and listening to heartbeats.(not that thats all that nurses do...I have huge respect for nurses)
But at that point in surgery that person is in the doctors hands and doesn't want to have to worry if the staff in the room is qualified enough to be there.She should of minded her own business until the surgeon or the assisting surgeon or the transplant doctor told that staff what to do with the harvested organ. Failure to communicate and now that poor donor is without an organ(or as they said there is no news....but how about the brother that donated it?? he gave a viable kidney and someone who should of minded her own business flushed it down the hopper.) I believe that it is truly the NURSES fault in this matter and no one elses. Case in point, everyone has a job to do in the ER and clearly this nurse thought she could just take it upon herself to clean as they went, which is against policy. She should be fired and her nurses license should be revoked. She was taught better in nursing school and she just didn't pay attention. So we are going to pay attention to her and make sure she never works as a nurse again. as for people saying shes human,she makes mistakes.........yeah she made a huge one.....she did something she wasn't suppose to do and she should be reprimanded for it, not just a slap on the wrist....
Molly, I totally agree with you. Each person is there for a reason and nothing should leave that room until surgery is over and all is accounted for in the process. It is scary the way people want to pass around blame while the one who made the mistake in the first place is the one who should get the blame. This type of thinking allows others to feel that they can do what they want since someone of higher authority is going to take all the real responsibility for their errors.
Molly, you're a decent one just as there are many decent nurses. That said, the story of the surgical tech in Colorado whole stole Fentanyl for herself and then placed her used needles back for patient use clearly demonstrates it's the person, not necessarily the profession to be blamed. Many people are now HIV positive thanks to this surgical tech. Tech, nurse or doctor--patients are relying on the "team" to get them back to a positive health state, not create additional problems.
With an emphasis on "former"........ with your understanding of the process, it is well that you left.....
I'll tell you a good one. A lady friend of mine had an abdominal hysto, her son works in the OR, she had a surgical sponge left in her for a year!!! She went through pure hell during that time, one doctor even told her "she probably had cancer". WTH?????
Yes, she is suing the hospital.
Think of the OR nurse that has to account for every single operating room materials ...they count and recount before and after the surgery. They even have them bar coded so if something is missing then they can figure out where it is. If your having an operation on a certain limb on your body mark it big with the word WRONG LEG, WRONG ARM, WRONG whatever....
I hope she wins big. There is no excuse if the procedure and counts of items are done correctly. This health care system is to be feared right now. It's going down the tubes just like everything else.
Damn!
Sorry, JMO, but RN's don't practice medicine, they practice nursing. And there is no "rushing" through the two year program to get an associate degree that requires four years to complete (two years for the actual nursing program, two years to complete general ed and prerequisites. In any other field, this would be a bachelor's degree). This RN, if that is what she was, didn't do anything to the patient's body, she cleaned up the room and threw away something she shouldn't have, something that shouldn't have been there in the first place. This doesn't sound like an RN to me and if it was, somebody messed up long before she got accidental custody of that organ. And that person's name has an "MD" on the end.
If the hospital has operating rooms is such a state that a NURSE cannot tell whether or not it was recently used.....Or employs nurses that cannot identify a diseased organ from a viable one......Maybe, just maybe there is more to this than meets the eye, "A woman scorned....." Just sayin'
Every person on that floor is responsible for this 'mishap.' Granted, the nurse may have assumed the kidney had been already removed, but aren't those containers sealed with the words 'live organ' taped to it? I feel genuinley sorry for all involved.
AMEN!!! I Am Still Totally Shocked by this story... What School Taught This Woman To Be A Nurse?
That just goes to show that there was a serious lack of communication with everyone in that staff. Nothing should leave that surgery room until it has been signed off by several of the medical staff. There should be a protocol in place and several processes checked off before anything leaves OR. It's unfortunate that this happened. I hope they learned from this other hospitals put some type of stringent process in place so this doesn't happen to them. I don't condone what happen but being a doctor or nurse or any type of caregiver is not an easy job. We can make rude comments and point fingers but sometimes things like this happen. Because it happen to me at the hands of an intern who had not had any sleep and was doing a simple medical procedure and botched it....
I used to work on a transplant service. The nurses should NOT be out on break - one person needs to be responsible for continuous observation of the kidney/cooler until it is given to the next team! How stupid can you be!
I have heard this story about 3 or 4 times and every time I still walk away scratching my head wondering " How Is This Hospital In Existence?" HOW DID THIS HOSPITAL STAY OPEN FOR SOOOO LONG? And Still Be Out Of Logical Control? Are the " Donated Organs " they have Already Put In People, Working Properly, Worse Yet.... Were the organs safe before this Hospital and it's Doctors Put the Donated Organs In????
I am a former OR nurse and to me this does not make sense. #1 Nothing( including the trash) ever leaves the OR until the surgery is completed and all the sponge / instrument counts are correct. #2 Tissue/organ specimens are ALWAYS labeled. #3 If the nurse did not know what was in the bag, I cant imagine her throwing something out that she did not know what it was.......even if it was not a vital organ, all tissue/specimens always go to the laboratory for a pathology report... I can't (or don't want to) believe a nurse would remove a large specimen from the OR and toss it in a hopper. Something does not add up here.
When I decided to become a nurse many years ago, I started as an LPN. To be accepted into the program, prospective students had to pass a test. That was the easy part. Next came the interview with the dean, Nursing instructor, and psychologist that the program hired. You better believe that these folks were looking for intelligent answers to their questions. Years later, when I went back for my associates degree, I took a test, passed, and never saw anyone until the day I started class. Pretty scary. As any "good" nurse will tell you. Nursing is 1% book smarts and 99% common sense. Needless to say, I graduated from my RN program with a bunch of book smart people. God bless the patients! Heard that a new hospital is being built in the area and only wants to hire graduate nurses so that administration can train them without any preconceived notions on how to nurse. Don't think I will be treated there.
Psychological tests and personality assessments are bunk. This has been proven.
Oh, and I will take a "book smart" healthcare professional any day over a healthcare professional with a great personality. Personality only goes so far......
As in most fields, "booksmarts" are worth little-to-nothing unless also mixed with a big dollop of (un)common sense. "Personality testing" isn't to see if someone has what is commonly referred to as "a great personality", but rather to see if a person's perception/thought processes are compatible with what they are attempting to make their chosen field. Hardly flawless, but not total bunk either.
She took a break? Yeah sure... she probably had to check her iPhone for the 100th time that day. That seems to be standard behavior for people at work these days.
Thirteen "Gallon" bag? She took a bag that large out of the operating room and no one noticed? Is "gallon" a typo? I am not a nurse, so I don't know if things are taken out of the room before the patient. However, someone should have noticed a bag that large. Why wasn't the nurse briefed on what was going on before taking over duty? This is a simple procedure for all shift work. Sounds like this hospital has serious procedural problems. I would review the whole program and fire those in charge if fault is found. Firing underlings do not improve these situations.
Even CNAs are not that dumb or careless. The nurse should lose her license.
Why was she removing the container in the first place? If it was needed to put the kidney in, and she didn't think the kidney was in it, why was she taking it out of the room?
How much experience did she have? Was she an RN or a LPN? And it's hard to believe anyone is that dumb and w/o supervision.. give her a lie detector test to make sure the kidney did not wind up somewhere else.
And when OBAMACARE takes effect, IF IT DOES, look for more than this kind of thing happening. Doctors DO NOT WANT OBAMACARE. Many will just close their doors, draw in their shingles and retire. Communications in OR's have been terrible for years and it gets to the point where operations have become just a business anymore and the human aspect is down the toidy. Why do you think they write on limbs with a marker ? Too much going on and too much confusion and lack of communication and poor direction. AM sure that nurse has died a thousand deaths for what happened. Her career is not destroyed. All over a mistake that could have been avoided if somebody had just done their job. Just ask YOUR doctor what OBAMACARE will do to his or her practice and then gauge your vote accordingly in November. I did and I'm voting for Mr. Romney.
Deb Take note that this did NOT happen under Obamacare. We need that medical assistance and it is the right thing to do for the American people. Bad practices will happen in a hospital with or without Obamacare which is just another word for insurance. Insurance is not the reason this person threw out this kidney. She just did a very stupid thing. I could not buy health insurance for my son because he had a heart condition. Obamacare will take care that people like him will live and have the same health care that healthy people do. Of course, that "caring" person Romney was asked that question in a debate and he said that it is just too bad but that is the business of health insurance. Everyone in his Republican audience applauded when he gave his heartless remarks. Someone even yelled, "let him die". Well, it is not the business of Obamacare to let people die through no fault of their own . Obamacare takes care of ALL the people. Out of touch, those are kind words for Romney. He can't begin to understand the lives of the average American.
Since some people want to politicize this thread, here goes. I can't relate to the millionaire son of a former millionaire auto executive and governor. But I can relate even less to a guy who was "affirmatively actioned" all the way through college and law school, and then attended (for twenty years) a chuch whose main message seems to have been that you don't have to love your neighbors if they aren't of your race for they are out to get you.
Rlquall - Interesting how you don't want to politicize this article then launch in to a narative that has nothing to do with health care and is totally politically biased. Wa! Wa!
Politicizing health care improvement - like most of the other Tea Party strategies - is monumentally stupid. Thanks for proving my point, Deb.