E-patients might have prevented Minnesota wrong kidney tragedy

Corrected 3/23/08: The hospital does have online patient records, though they don’t include CT/MRI or mammogram results. See link and details below.

This one strikes close to home, landing a year after removal of my own cancerous kidney … plus, a year earlier, I lived 15 miles from this hospital. So this could have been me.

Article: Doctors remove cancer patient’s healthy kidney by mistake

Apparently, a few weeks before surgery somebody marked the chart wrong, saying the wrong kidney had the cancer. From that point on, things went exactly according to procedure. …


The error wasn’t discovered until the day after surgery, when the pathologist basically said “Um, there’s no cancer in this thing.”

Defenders of the Walled City approach to medicine, please note: this was not caused by empowered patients Googling for medical information on unsafe web sites. To the contrary, can there be any doubt this could have been prevented if empowered patients and their families had been involved, with full access to their records, and had been reading them? (Please read the e-Patient White Paper, PDF or Wiki version.)

Patients MUST have access to their records, as PatientSite and similar sites allow!

Correction 3/22/08: Park Nicollet Methodist Hospital does have partial online medical records, through its Patient Online system. I briefly tried the guest tour – interesting comment in the Reports section: “Reports currently include only simple x-rays. All other reports, such as CT/MRI and mammograms, are not yet available on Patient Online.”

Please note, too, that this was not a slacker hospital – to the contrary

  • according to the Associated Press, “It had been a point of pride at Methodist Hospital that Gov. Tim Pawlenty came there four years ago” to sign the bill creating Minnesota’s first-in-the-nation adverse health event reporting system
  • Member of quality/safety advocate The Leapfrog Group
  • Many awards
  • Patient bill of rights & responsibilities. (I’m not sure I agree with it all, and I don’t see anything about access to one’s records.)

And yet, they had no requirement to verify surgical sites using diagnostic imaging. (Now they do.)

Look: Humans make mistakes. I’ve caught a couple of errors on my own radiology reports, and have had them corrected. Both were very minor compared to this. (One identified me as a 53 year old woman. Sure caught my eye. It took two requests, but I insisted they fix it.)

It should be MANDATORY that patients be given online access to their records, and should be ENCOURAGED to read them. (Offline paper access is not sufficient; it’s not constantly up to date, it’s not convenient enough to actually get used, and not easily shared with distant helpers. Get the data in the system, and get it published online!)

On top of the family tragedy, I cannot imagine what life is like right now for the surgeon who wrote that one wrong thing on the chart. Can there be any better example of the e-patient tagline “because health professionals can’t do it alone”?

If motivated “family proofreaders” had been looking over everyone’s shoulder, the worst this would have amounted to is an angry “Man, that was a close call. How did that happen??” But, now look.

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Comments

7 Responses to “E-patients might have prevented Minnesota wrong kidney tragedy”

  1. Such a tragic, but instructive incident.

    Two weeks ago, when I was boarding a Southwest flight, someone mentioned the NY Times story about the safety ratings for some its planes (which have since been grounded for repairs). “As long as the pilot is on-board with us, I’m OK,” I replied. “When we start to fly on automated aircraft, I’ll want to see my plane’s safety ratings before I fly.”

    No one pays attention to detail like the person whose life depends on it.

  2. Ted Eytan says:

    Dave,

    Thanks for reporting this – no one wants an outcome like this. And as you state, it’s preventable by involving patients in their care, not only in reading their records, but in creating them with their doctors in the first place. When a note is written in front of a patient, it’s a great opportunity for them to correct things before a mistake gets placed in the record in the first place.

    One suggestion is that the next time a person goes to the doctor and they are using an electronic system, ask them to show you what they’re writing as they write it, and even for them to print out a copy for you before you go. Over time, people will realize that this only improves care.

    I usually explitly state to patients, “I would like you to see this, no secrets.”

  3. William Utz says:

    Dear Mr. deBronkart,
    As a practicing clinician in the field of Uro-Oncology over the last 17yrs, as Asst.Clinical Prof. of Urology at the U and past president of the Minnesota Urological Society, I feel I must respond to your well intended comments re: this recent tragedy at one of our regional hospitals. Although certainly not opposed, and in fact, would support the basic premise of your arguement, that this could potentially been avoided if patients had access to there records on line, in fact the unfortunate culpability rests solely in the hands of the surgeon. The two training programs that I have and am currently involved with(Mayo and the U), have absolute,stringent policies that are never voliated as does the clinical practice at Urology Associates: no incision or access to the pt. is undertaken unless the films are IN THE ROOM when surgery is performed on bilateral systems(ie. kidneys, testes). This is a steadfast policy that simply stated must be adhered to. In my 25 yrs of practice (and collectively our group’s practices of over 215 cumulative years), this has never happened nor has anyone been aware of a similar event(removal of the wrong kidney). Although I am sure it has happened before, my point is that most Urologists already have taken steps to prevent this tragic and exceedingly rare outcome. Simply having access to your records with the belief that the dictated report is, in fact accurate, will not completely eradicate the chance for a mistake as I have seen, on rare occasion, the wrong side body part described in a radiology report…and of course immediately corrected the report. The ONLY way to ensure this “ultimate of mistakes” can never happen is to, in fact, have the actual films in the OR room and review them before surgery. It is our groups policy that BOTH the surgeon and assistant view the films and are in agreement BEFORE positioning of the patient is undertaken.Only then can we be assured that the correct body part is the subject of interest.
    As bad as I feel for my colleague, the patient and his/her family are in my thoughts and prayers.
    With regards, Bill Utz MD FACS

  4. Wrong site surgery and it’s prevention is one of many adverse events discussed in my book entitled “The Empowered Patient: Hundreds of life-saving facts, action steps and strategies you need to know.”

    Patients and their loved ones are an untapped safety resource. Once the public is armed with the right information, many of these needless and preventable errors will be eliminated.

    Julia Hallisy

  5. I think it might be useful for us to abstract ourselves from the details of this case and think about the situation in general terms.

    In any system as carefully choreographed as health care, and in my work, a health information system, it only makes sense that every actor has a role in making it safer. This is what the Toyota Motor Company has done throughout its history, and what we implemented in our care institution.

    We found that it was important that the Medical Director of Informatics be aware of all potential safety threats. But that is not enough. Every patient, nurse, and physician must also be aware. And when they believe there is a problem, it is taken seriously. By taking seriously, we mean a scripted answer to every query that is something along the lines of, “Patient safety is very important. How can I help?” A staff member or patient should never feel uncomfortable in bringing problems forward.

    What Toyota did is apply a democratic process to discovering errors, and I have found this works very well in health care, when we step back and think about it from our patients’ perspective.

    We wrote about this in our blog on LEAN in Health Care about a year ago:

    http://www.dailykaizen.org/archives/236

    Unfortunately, the first time something happens in a health care situation can often be one time too many, so even the potential of it happening must be seen as discovered gold, not something to be buried.

    Our patients want to be our partners in supporting a safe health care system. Being a partner means that they have all of the information that we do.

    Thank you for bringing up this important issue.

    Best regards,

    Ted Eytan, MD

  6. Dawn says:

    I work for a company called LifeWings that teaches hospitals how to use the same teamwork training and safety tools that have made commercial aviation so safe and reliable. And it works! Hospitals who use our system have eliminated errors like removing the wrong kidney and dramatically improved the safety of their care. Many of them have won awards for the quality of their patient safety.

    If I had a choice, I wouldn’t go to any hospital that didn’t use our LifeWings safety system.

    We are out there making a difference in patient safety every day. Over 85 organizations use us. Find out if your hospital is on the list. Visit LifeWings at http://www.SaferPatients.com.

  7. Dawn, is your comment just a drive-by ad or does it have anything to do with e-patient principles, as discussed in this case?

    I don’t mean to sound too noodgy so if I’m missing something please point it out and accept my apologies…

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