A recent article from Toledo Blade discusses how a UTMC nurse tossed out kidney, and ruined it.
The story is tragic. A man wished to donate his kidney to his older sister. After it was surgically removed from the donor, it was misplaced. For over an hour no one knew the whereabouts of the missing kidney. It was finally discovered in medical waste and was determined to be unusable. The doctors involved decided with the family that it would be best to no go forward with transplanting said kidney.
The loss of the kidney is tragic. But luckily the patient has a high chance of finding a compatible donor and no lives were lost. However, something else tragic has occurred in this care.
A nurse was blamed for the botched procedure.
The Toledo-Lucas County health commissioner gave confirmation that a nurse accidently threw out the kidney. “One of the kidney doctors talked to me,” Dr. Grossman said. “He said it had to do with one of the nurses disposing of the kidney improperly. He didn’t try to hide anything from us.”
What’s disturbing about this is that “one of the doctors” hand over 2 nurses on a silver platter to the court of public opinion.
While the evidence in this incident is not available, revealing information like this to the public is a terrible stab at the nursing profession.
Having been in a OR setting, I find it difficult to think that a couple of careless nurses simply threw the kidney out on accident. What could have been going on in the environment for the kidney to be misplaced? Were the nurses understaffed? Were the uninformed of the need for the kidney to be transplanted? Did another member of the OR team tell the nurses to dispose of the kidney?
Considering that there were 16,816 kidney transplants last year, it’s a sigh of relief to read that this sort of incident is thought to be a one-of-a-kind ordeal.
The article mentioned above calls out the suspected nurses by name and notes that they were suspended with pay. But one has to wonder what type of turmoil this public discussion could have on their lives and careers. The post is already flooded with facebook responses. Some of them even identify themselves as nurses who work for the hospital mentioned. (This is a HUGE social media mistake!)
Some of them bash nurses and call some people (obviously referencing nurses “idiots”
One nurse simply questions “What are we doing wrong?”
A political commentary adds snark and politics to the situation. This comment no doubt a pun on the “You didn’t build that” statements that president Barack Obama made recently.
One comments that nurses “would rather tear out their own kidneys with their bare hands” than have this happen to a patient.
One insightful commenter discusses the possibility that the nurses are short staff and stressed. Could this be a potential factor in the loss of the kidney?
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A generalization about how nurses aren’t competent.
The donor transplant program at University of Toledo Medical Center has been temporarily halted while they investigate their process. But with a $2 million grant waiting in the wings, this suspension likely will be short.
This event needs to be deeply investigated and used as a learning experience. When capable facilities are unable to perform transplants, people could lose their lives.
“As of Aug. 17, there were 2,688 people in Ohio waiting for a kidney and 92,841 people waiting nationwide.” And those kidneys aren’t going to transplant themselves.
Still, it’s upsetting that 2 nurses were called out and blame completely placed upon them without the full investigating being complete. The entire team is at fault for this potentially deadly mistake, and it’s disturbing to read that nurses are instantly being hung out to dry.
What are your thoughts on this incident?
Do you think it is appropriate for the nurses to be named in the article?
Have you ever know a nurse that was public blamed for a medical error?
How did they deal with it?
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If the entire procedure revolved around the kidney extraction and there was an assumed simultaneous team prepared for insertion (unlikely since they were looking for the organ an hour later) it seems everyone would be kingly focused on the kidney. It’s like losing a car on an assembly line. Workers are bound to notice an irregular diversion.
Someone was clearly not briefed on the procedure and may have tragically assumed that the extraction was deseased, cancerous, etc. Where does the responsibility to inform those assisting of the surgical intent? Is it really a “team” if one member is thinking cancer excision and another is thinking transplant?
There must have been some sort of big distraction during the procedure. Did the donor’s vitals drop, requiring full attention of the team? Likely the investigation will address these questions.
Regarding the ‘throwing of the nurse under the bus,’ apparently fear of malpractice, tarnished reputation and embarrassment moved the doctor’s lips. As you point out, however, this results in unfavorable consequences or the named nurse.
I want to know what else was going on in that Operating Room. Singling out one person to blame in a team process is a dangerous practice and I’m suspicious about the dynamics. I’ve done some work with OR staff and would like to share these two blogposts that show there is a lot more going on than is necessarily visible.
1. Communication Dynamics & Patient Safety in the Operating Room: Insights for Surgeon, Nurse, Patient Advocate & Administrative Leaders
http://www.confidentvoices.com/2012/04/16/communication-dynamics-patient-safety-in-the-operating-room-insights-for-surgeon-nurse-patient-advocate-administrative-leaders/
Can Facilitated Discussions on Bullying be Fun & Helpful? Turning Resistance into Engaged Commitment for Change!
http://www.confidentvoices.com/2012/05/14/can-facilitated-discussions-on-bullying-be-fun-helpful-yes-with-elephants-ships/
Maybe, MAYBE this nurse is at fault, but we need more information and should be cautious about accepting this determination!
Beth
Any of us who have ever worked in ANY hospital under any capacity know that this is not simply the nurses fault but a breakdown in the whole team. Very rarely in medicine does a mistake rest on solely one persons, medicine especially surgery is based on a team effort and often breaks down to lack of effective communication. I think it is sad that the doctor has literally thrown the nurses under the bus in this incident, but not unexpected.
In this day and age of medicine nurses are given the task of being “the last check and balance” for just about everything. If a Dr. writes an order it is the nurses job to not only carry it out but to also check to see if it is appropriate and if it is not to take some sort of action. We are required to check on medications ordered and if the pharmacy and Dr. have allowed something to get to the patient that is unsafe it is our job to recognize it and hold that medication. I could go on and on but suffice to say that the point is made. With this sort of responsibility heaped on nurses shoulders it should surprise no one that it is easy to point the finger at the nurses in the end, because they are “the last line of defense” against these sort of mistakes.
Which leads me to ask this question: In the struggles for nurses to seen as professionals and not just handmaids to the Dr.s have we just set ourselves up to now be the legal scapegoats?