Kenyatta National Hospital chief executive officer Lily Koros appears
before the National Assembly Health Committee on January 26, 2018 over
alleged sexual assault of female patients. Four medics have been
suspended over malpractice. PHOTO | JEFF ANGOTE | NATION MEDIA GROUP
A neurosurgeon has been suspended for opening up the head of the
wrong patient in one of the worst cases of medical malpractice to
become public at Kenyatta National Hospital.
Two men had been wheeled into KNH unconscious last Sunday.
One
needed head surgery to remove a blood clot in his brain while the other
only required nursing and medication to heal a trauma swelling in his
head, medically known as closed head injury.
However, a horror mix-up of identification tags saw the wrong man wheeled into theatre and his skull opened.
Doctors
did not realise the mistake until hours into the surgery, when they
discovered there was no blood clot in the brain of the man sprawled on
the operating table.
PROCEDURE
They had cut open the head of the wrong patient in a dizzying case of medical malpractice that once again casts the spotlight on the country’s biggest referral hospital.
They had cut open the head of the wrong patient in a dizzying case of medical malpractice that once again casts the spotlight on the country’s biggest referral hospital.
The mix-up also raises questions about pre-surgery procedures in
Kenyan hospitals, especially on how to ensure the right patient is
operated on the right place.
It also calls to question doctors’ lack of commitment to their patients to ensure they receive the care they need to get well.
The Daily Nation,
which investigated the scandal since Wednesday, will not publish
details of the patients out of respect for their privacy and because it
was not clear on Thursday if their families had been informed of the
operation.
Last evening, hospital management threw out
this reporter by dramatically having security guards escort her out of
the premises for making enquiries about the incident.
MEDICS SUSPENDED
In an effort to limit the damage following our enquiries, the hospital’s chief operating officer Lily Koros issued a statement announcing the suspension of four medics who were at work on the fateful night.
In an effort to limit the damage following our enquiries, the hospital’s chief operating officer Lily Koros issued a statement announcing the suspension of four medics who were at work on the fateful night.
They included the neurosurgeon, the ward nurse, theatre receiving nurse, and the anaesthetist.
“The
management has suspended the admission rights of a neurosurgery
registrar and issued him with a show-cause letter for apparently
operating on the wrong patient,” Ms Koros said.
The
fact that Ms Koros was referring to the operation as “apparent” is
probably an indication that the hospital was unwilling to publicly admit
the error, and also that some of its procedures may have put the
welfare of patients at risk.
IDENTIFICATION
She did not disclose the identity of the patients, only saying that the hospital will “advise on the cause of action to be taken”. The doctor’s suspension ends Friday.
She did not disclose the identity of the patients, only saying that the hospital will “advise on the cause of action to be taken”. The doctor’s suspension ends Friday.
The patients were received and
both admitted in the hospital’s Ward 5A, which houses general surgery
and trauma patients without fractures.
Patients wear
name tags on their hospital gowns in this ward and investigations will
look into how the two were given the wrong tags.
The tags are the patient’s only method of identification.
It
appears in this system, the surgeon will have no contact with the
patient, waits in the theatre, and follows the information in the files
to carry out critical surgery.
“The staff in theatre
had no way of telling they were operating on the wrong patient because
he was unconscious,” a source, who requested anonymity because of the
sensitivity of the matter, said.
“Besides, the file details and patient label tallied.”
SURGERY STOPPED
The team only realised the mistake more than two hours into the operation after opening the head of the wrong patient, only to find a swollen brain but no blood clot.
The team only realised the mistake more than two hours into the operation after opening the head of the wrong patient, only to find a swollen brain but no blood clot.
After consulting a senior
neurosurgeon on call, the operating doctor was instructed to proceed no
further, clean up the area and close the head.
The doctor examined a CT scan of the patient and his file before recommending surgery.
Both showed that there, indeed, was a blood clot in his head.
However,
the scan was from the wrong patient and the team did not discover the
mistake until after the surgeon was halfway into the operation.
RECOVERY
In a miracle of some sort, the Nation was informed that both patients were in good condition, and that the one who had a clot might not undergo surgery because he had improved significantly.
In a miracle of some sort, the Nation was informed that both patients were in good condition, and that the one who had a clot might not undergo surgery because he had improved significantly.
Few medical errors are as vivid and
terrifying as those that involve patients who have undergone surgery on
the wrong body part, undergone the incorrect procedure, or had a
procedure intended for another patient.
These
“wrong-site, wrong-procedure, wrong-patient errors” (WSPEs) are rightly
termed “never events” — errors that should never occur.
Wrong-site
surgery may involve operating on the wrong side, as in the case of a
patient who had the right side of her vulva removed when the cancerous
lesion was on the left, or the incorrect body site.
No comments:
Post a Comment