State officials fined St. Jude Medical Center in Fullerton $100,000 for a mistake in record-keeping that led to the removal of the wrong kidney from a patient. It was the hospital's fifth administrative penalty, according to the California Department of Public Health.
The patient had been diagnosed with cancer to the right kidney, but a pathologist informed the physician after surgery that the organ was normal, according to state documents that indicate a check of medical records showed it was the left kidney that needed to be removed. St. Jude officials notified state officials about the mistake in February 2012, according to the health department's announcement Thursday.
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We don't know how the patient is doing now because of confidentiality laws.
St. Jude responded to the state fine with a statement:
This tragic error began long before the patient's admission to the hospital; however, the responsibility belongs to us. While completing the pre-surgical checklist, our staff matched and cross-checked the information with the patient and the surgeon, and the responses were consistent with the documentation that the hospital received.
Pathology discovered the error shortly after the surgery, and our immediate concern was for the patient and family, and to help them find the most effective treatment options available.
Unfortunately, in this case the images were performed outside of our facility, and were not available. Instead of repeating the images for confirmation, we relied on the consistency of the documentation. Ultimately the inability to directly compare the report to the image resulted in not identifying the error.
As a result, we have put stringent safeguards in place to ensure this protocol is followed completely, and we have implemented a safe scheduling process that requires documentation, and images to be submitted in advance of the surgery.
The procedure cannot and will not be scheduled until the appropriate images are submitted. We also require that images are viewed as part of the safety check. If the images are not available, the surgery will be delayed until the images are available.
Protecting the health and well-being of our patients is fundamental to our mission and values. While this situation is unique, in that the chain of events began long before the patient was admitted to the hospital, we thoroughly investigated and identified every possible area of improvement.
Through transparency and collaboration it is our hope that other hospitals will also learn from our experience, making surgical procedures safer for all patients.