The State Department of Public Health has fined a San Diego hospital $75,000 for removing the wrong kidney from a man in 2010, the department announced Thursday.
According to the department’s report, an 85-year-old man went in for surgery at the Kaiser Foundation Hospital in Grantville to have his left kidney removed. Doctors had found a cancerous tumor on the kidney prior to the surgery.
Just before the surgery, the surgeon marked the right kidney area, instead of the left.
He told investigators that he could have accessed a CT image to confirm which kidney was to be removed, but he didn’t feel it was relevant to the case.
The right kidney was then removed and sent to a pathologist at the hospital. Later, the pathologist informed the surgeon there was no cancerous tumor mass in the kidney that was removed.
In subsequent interviews, the department learned the patient pointed to his right side during a physical when he was describing where he felt pain. The patient, referred to in the report as Patient L," then signed a surgical consent form to have his right kidney removed.
However, CT images showed the cancerous mass on the patient’s left kidney. The department found that the mistake could have been prevented if the surgeon had looked at the images.
“During the [surgery], the relevant images related to Patient L were not utilized,” the report states.
A statement obtained by NBC 7 San Diego from the hospital says that staff "immediately reported the matter to the California Department of Public Health (CDPH), and cooperated fully with their investigation.”
On page 5 of the report, the department wrote that the hospital administration did not provide a report on the error. They found out about the error when the hospital released the patient’s medical records to them, informing them of the surgery.
"The incident occurred on Saturday, December 18th, 2010 and we notified CDPH on Wednesday, December 22, 2010," a separate statement from the hospital reads.
As a result of the error, the patient often experiences fatigue and depression and has additional dietary restrictions, his wife told the department investigators in the report.
When interviewed by the department, the man began to tear up describing how the surgery has changed his lifestyle. He said can’t do many of the things he enjoyed before the erroneous surgery, such as dance and play golf. He also has become dependent on his wife and other family members to assist him with every-day activities such as shopping.
This is the hospital’s second administrative penalty, the department said Thursday.
In response, the hospital issued this statement (in part):
We sincerely regret that this error in 2010 occurred at the Kaiser Permanente San Diego Medical Center. While these types of incidents are very rare, we take the matter extremely seriously.
The statement went on to describe the measures the hospital has taken to make sure errors like this one don’t happen again.
“[The measures include] implementation of a multi-disciplinary surgical safety team that meets weekly to discuss ideas for continuously promoting safe operating practices. This plan was accepted by the CDPH in May of 2011 and was fully implemented at that time.”
In total, 12 California hospitals were penalized, with fines totaling $785,000. Investigations found the hospitals’ errors caused or likely caused serious injury or death to patients.
Research released Wednesday by Johns Hopkins University shows that of all malpractice claims in the U.S., one in four of the claims were of surgeons performing surgeries on the wrong body part – similar to the case at Kaiser in San Diego – the study found.