Case of the Right Kidney
Posted on 13. Aug, 2009 in Case Reports
Case Synopsis
About Margaret
It was April of 2003 when Margaret*, then a 65-year old woman, visited Dr. Arnold* because she was experiencing kidney failure. Dr. Arnold was a board certified urologist who had been practicing in Maryland since 1977.
Margaret suffered other medical ailments such as high blood pressure and has had intestinal bypass surgery for morbid obesity. She has been treated many times for urinary tract infections, 
needed to urinate overly frequently, had kidney stones, as well as intermittent flank pain that required her to be treated in the emergency room.
Just a little background, before Margaret visited Dr. Arnold, she had three radiologic studies done. She had an MRI, NM Renal, and an Abdominal Ultrasound which all showed her right kidney more diseased than her left.
Visit with the Urologist
On that first visit to Dr. Arnold on April of 2003, the doctor found that Margaret had no flank tenderness on either side. He diagnosed Margaret with bilateral renal atrophy, left kidney stone, and right hydronephrosis. A month later, Margaret went for a NM Renal Captopril study which basically showed the right kidney with decreased function, but the left side with normal function.
The next visit was almost half a year later in December when Margaret was having pain on her left flank. On January of 2004, Dr. Arnold performed a cystoscopy, a test to look at the inside of the bladder and the urethra using a thin, lighted instrument. At the same time, Dr. Arnold attempted to see if he could get fluid to move backwards into the kidneys to check if there were any blockages. The left ureter flowed without problems. The right side was blocked.
Oops – the Initial Mistake
The same day, an interventional radiologist, Dr. Baker* was consulted to place a stent but was unable to do so. Dr. Baker then performed an ultrasound and then a CAT scan of Margaret’s kidneys. In his written report, Dr. Baker confuses the right and left kidneys. He wrote that the right kidney was normal, but the left had no function.
Dr. Baker called and gave Dr. Arnold his report. Dr. Arnold then called Margaret and informed her and her son that the obstructed kidney would result in infections and pain. He recommended that the kidney be removed. A few days later, Margaret calls Dr. Arnold’s office to proceed with the nephrectomy procedure to remove her kidney.
The Surgery
The big day came February 6, 2004. At the hospital, Margaret confirmed that she was to have her left kidney removed and described that her pain was on the left side. As is standard procedure, Dr. Arnold marked Margaret’s left side in the presence of a nurse and Margaret’s two adult sons. The consent form reads: LEFT Radical Nephrectomy. (LEFT was written in all caps).
In the operating room, Dr. Arnold placed the CT scans on the view box. Unfortunately, they were placed flipped around because Dr. Baker did not note on the scans that he had taken the films with the patient laying face down (instead of facing up).
As the surgery finished, Dr. Campbell, who was assisting Dr. Arnold with the nephrectomy, noticed that something was wrong. The rest of the organs on the CT scans did not match up correctly. It was then that they realized that they had removed the wrong kidney.
Most certainly in panic on realizing the potential mistake, Dr. Arnold double checked the medical charts. He wrote an addendum to his operative report:
At the time I recognized that most probably there has been a mistake in removing this kidney so I went back and checked the CT scan which I thought was done in the prone position and that was why this left side was the worst. I also checked with my office and it was told to me that the patient was posted for a left nephrectomy, but the actual reports in the past have shown that the patient had hydronephrosis and poor function on the right side. The patient was returned to the recovery room and I went ahead and talked to the patient’s son, …., and his brother, and told them that the mistake has been committed and by mistake I removed the left kidney instead of the right and I was very sorry about it. This will also be conveyed to the patient when she wakes up.
Case Outcome
Because that was Margaret’s only functioning kidney, she had to begin dialysis treatments soon after the surgery.
Dr. Arnold had his license publically reprimanded and placed on three years probation for failing to meet the standards of quality care by erroneously removing Margaret’s functioning left kidney. In addition, he was required to enroll in a Board-approved course of extensive duration in patient safety/risk management.
For his contribution to this medical mishap, Dr. Baker was publicly reprimanded for violating the standards of quality care and had failed to keep adequate medical records.
Analysis by Lyssa
At first glance, this just seems to be a very unfortunate case of negligence on the part of the doctors involved. The saddest part is that the patient bore the brunt of this accident. Our healthcare system understands that doctors are not perfect, and that is why doctors work with each other on major cases, especially surgeons. Most of us would look at this story and wonder how we can trust our doctors (or our system, for that matter) when THREE doctors could not catch the mistake until it was done. Let’s look into how this happened.
Dr. Arnold had been practicing medicine for over 25 years, was a well-qualified urologist, and as far as we know, has not had any other egregious mess-up in his record to this date. This makes this case even odder because, as her doctor, he should have noted on all her charts that it was the right kidney not functioning – his first diagnosis. He should have caught the mistake during his correspondence with the radiologist, Dr. Baker, who was actually the first one to make the mistake. What is likely is that Dr. Arnold did not even bother reading the report or comparing any of his notes. Perhaps he was too busy or stressed, but certainly neither is a good excuse. Doctors are expected to at least familiarize themselves with the case before meeting with the patient.
This lack of cross-checking is the root of the entire mishap. The patient was then told that the left side needed to be removed. Now, this patient was 65 years old, likely not the sharpest patient. She probably got lost in a lot of the medical terms thrown at her, and only knew that something was wrong with her kidneys. Plus, what was there to not trust about her doctor? Perhaps we could lay some blame on her sons, although we don’t know the extent of their awareness of their mother’s medical issues.
Another cross-check failed during surgery, where there were TWO surgeons, Dr. Arnold and Dr. Campbell, that operated on Margaret. It was only afterwards that Dr. Campbell realized the error, and by then it was too late.
To me, the doctors involved in the case rushed too much, and did not bother checking up on each other’s work. While the most heavy offenders, Drs. Arnold and Baker, were disciplined, in my opinion, all three doctors should have gotten reprimanded. The patient should also have to pay nothing for her needed treatment resulting from the error.
What is even worse is that events like this one is not uncommon at all. Miscommunications and failures to double-check result in many, many errors by healthcare professionals. Many do not have as far-reaching consequences as this one, but it just illustrates how little we should trust what doctors say and to be aware of our own conditions.
| Score |
|---|
| 5 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 8 | 3 | 8 | 5 | 1 |
Response by Marc
While I agree with most of your analysis, I think Dr. Arnold made an honest mistake. I can’t imagine him snickering in the back thinking “mwahahaha, I’m going to take out her other kidney to see what happens!”
Should Dr. Arnold have checked his notes? Absolutely. Double checked? Of course. Triple check? At what point does this stop? From what I gathered, he checked his consent form – LEFT. He checked the CT scan – LEFT. He checked with the patient – LEFT. He marks the patient in front of her two adult children – LEFT.
Sure, I empathize with Margaret. She now has to suffer a lifetime of dialysis or kidney transplant because of a medical mishap, but I can’t solely place the blame on the doctor. She was the final safeguard to her own body. If Margaret would have just kept up more on her own condition and taken more ownership of her health, this mistake would not have happened.
| Score |
|---|
| 4 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 8 | 2 | 2 | 7 | 1 |
Response by Florence
This is such a sad case, and my heart goes out to the patient and her family. I think this case just proves you can never be too careful about your own health. Never rush into surgery without knowing exactly what you are getting yourself into.
I know I get lost in all the terms thrown at me while at the doctor’s. However, I’ve learned to ask more questions until I’m satisfied with the answer. Doctors always seem like in a rush and I almost feel guilty for keeping them longer, but it is better safe than sorry. This story is a good example of why we must do that.
Yes, I think most of the blame is on the doctors. The patient cannot very well diagnose herself! Unfortunately, as I mentioned, doctors are so rushed now that they have to balance all their patients. They have only so much time to spend on one person.
No matter who you blame here, I think the best lesson to take out of this is to make sure you understand your own health completely.
| Score |
|---|
| 4 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 7 | 6 | 4 | 2 | 1 |
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