Dena Knapp says a surgeon at Avera McKennan Hospital in Sioux Falls, SD mistakenly removed her kidney. Knapp has filed suit against the surgeon and his practice.
Knapp was scheduled for surgery on October 5, 2016 to have an adrenal gland, along with a mass on the gland removed. Dr. Scott Baker removed her kidney instead.
Later that same day, Dr. Baker was informed by the pathology department that he had removed the kidney, instead of the adrenal gland. However, two days later he told Knapp that he had not heard back from pathology yet.
On October 11, Dr. Baker informed Knapp that he had not gotten everything, and that she would need to undergo a second surgery.
Knapp made the decision to go to the Mayo Clinic in Rochester, Minnesota to have the second surgery, instead of returning to Dr. Baker. A Mayo Clinic surgeon successfully removed the gland and mass.
According to the lawsuit, “Knapp’s erroneous surgery resulted in an incurable and progressive kidney disease in her remaining kidney…she suffers from pain, fatigue, depression and mental distress…further, since the erroneous surgery, Dena has been unable to perform many functions and has required replacement services to clean and maintain her home, the past and future cost of which is yet to be determined.” (USA Today)
In South Carolina, an operating room employee noticed an expired date on an artificial ocular lens implant, just before a cataract surgery was to begin. No one checked the expiration date until 20 minutes before surgery. Lorri Gibbons, vice president of quality and safety for the S.C. Hospital Association said, “If the expired implant had been used, the patient may have developed an infection and would have needed another surgery to replace the artificial lens. Gibbons said using the 19-point “Surgical Safety Checklist” prevented the dangerous mistake from being made. “They caught it just in time…This (checklist) has become such a good communication tool.” (The Post and Courier)
In 2010, South Carolina hospitals were asked to participate in a voluntary program to implement this World Health Organization Surgical Safety Checklist. In the hospitals that completed the study, South Carolina saw a 22 percent reduction in post-surgical deaths.
“In the Safe Surgery South Carolina program, all hospitals in the state were invited to participate in a voluntary, statewide effort to complete a twelve-step implementation program with Ariadne Labs that included customizing the checklist for the local setting, doing small scale testing, and observing and coaching on checklist performance.” Harvard T.H. Chan School of Public Health Fourteen hospitals (40 percent of the inpatient volume in the state) completed the study.
Post-surgery, “patients are at risk of complications and death from a variety of causes such as infection, hemorrhage, and organ failure.”
Findings: In 2010 (prior to implementation) the post-surgery death rate in these 14 hospitals was 3.38 percent, and decreased to 2.84 percent in 2013 after implementation. Mortality in the 44 hospitals that did NOT participate in the program was 3.5 percent in 2010, and 3.71 percent in 2013. That’s a 22 percent difference in mortality between the two groups!
“With these results, South Carolina offers a national model of best practices in implementing a team-based, communication checklist to drive quality improvement in the operating room.”
Gibbons said, “None of us went into health care to hurt people and when it happens, it’s devastating personally, and professionally. And if something as simple as improving communication around the patient so that…everybody is more likely to say, we’re on the wrong leg or we’re hanging the wrong bag, that is what’s saving lives.” (Greenville News)
Hopefully hospitals around the country will begin to implement this (or a similar) checklist, creating “a culture of operating room communication that improves overall surgical care and safety.” This will prevent many errors and even deaths.
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