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CMS - Medicare Living Kidney Donor

Official Report of Toledo’s Thrown Away Living Donor Kidney

Read the full report here.

The following are excerpts from the report. Any and all emphasis is mine.

 

The clinical record review revealed Patient #9 was admitted to the facility on 08/10/12 with a diagnosis of kidney donation. A pre-operative progress note dated 08/10/12 stated the planned procedure was a right laproscopic donor nephrectomy. A review of the operative report for the procedure, dictated on 08/20/12, revealed after the kidney was removed, it was wrapped in a lap sponge and placed in a slush machine and covered with additional cold slush.

The report documented the circulating nurse, Nurse B and the scrub nurse, Staff B (the ‘scrub tech’ according to the case staff list) were informed the kidney was in the slush machine. The report stated, “As the skin was being closed it became apparent that the kidney was no longer in the slush machine”  and “investigation of this fact revealed that the circulating nurse had inadvertently discarded the kidney.”

Circulating Nurse A, who inadvertently disposed of the kidney, was interviewed on 08/16/12 at 12:45 PM. Nurse A stated that soon after the kidney was removed she was relieved for break by the relief circulating Nurse B. According to the facility’s investigation Nurse A left for lunch at 12:15 PM, after giving report to Nurse B and returned to the operating room after lunch at approximately 1:05 PM. Nurse A stated that because she was on break she wasn’t in the operating room when the surgeon announced the kidney was being placed in the slush machine.

Nurse A stated she took the contents of the slush machine, without realizing the kidney was within the slush, left the operating room, [went] down a hall and into a dirty utility room, and flushed [it] down a hopper.. Nurse A stated she thought the kidney was in the recipient’s room because that is what usually happens.

 

The tour [of the operating room] revealed Nurse A had to have walked one-half the square room’s perimeter and past Nurse B and Staff B to take the contents of the slush machine from one corner of the room to the only exit door, and then down the hall to the soiled utility room that contained the hopper.

 

Nurse B also stated that she never saw Nurse A leave the room with the contents of the slush machine.

Scrub technician Staff B said that she was responsible for the slush machine, but did not notice Nurse A take its contents, which included the kidney, out of the room.

Physician A, anesthesia resident, and Physician B, transplant surgeon, both stated that they did not notice Nurse A’s activity around the slush machine, or her leaving the operating room with its contents.

Staff C, administrative staff, said they have not yet figured out how circulating Nurse A could take the slush with the kidney in a 13-gallon size bag out of the room without Nurse B, Physician A and B, and Staff B not noticing anything out of the ordinary.

 

 

PS. What the report doesn’t say but the early media reports did is that no one noticed the kidney was missing for an hour. Standard procedure is for a donor kidney to be removed, rinsed and immediately taken the recipient’s OR. What was going on that the kidney was left unattended in the slush machine for an hour?

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