Wrong kidney probed in blunder

PUBLISHED : Saturday, 28 April, 2012, 12:00am
UPDATED : Saturday, 28 April, 2012, 12:00am


A tube was inserted into the wrong kidney of a patient at a hospital due to a mix-up by the chief surgeon, the Hospital Authority said yesterday.

The patient was having a ureterorenoscopy - in which a fibre-optic endoscope is inserted to allow a visual check for abnormalities. His right kidney was to be examined but the procedure was carried out on his left one, the authority said.

The error was not noticed until the procedure on the left kidney was completed; the right one was then checked.

The blunder was disclosed by the authority yesterday in its newsletter. The doctor, patient and hospital were not named. The authority only identifies offending hospitals when the mistake results in serious harm or serious potential harm to a patient.

In the latest incident, the scrub nurse was aware of the mistake but failed to speak up. The newsletter did not mention any penalty or disciplinary action.

The procedure involves inserting a thin tube into the ureter, which takes urine from the kidney to the bladder, and the kidney itself.

Medical Association president Dr Choi Kin said there was a risk every time the procedure was performed.

'The tube going through the ureter can be pinched each time the operation is performed. It can result in an infection. The extra risk to the patient could have been prevented if the doctors had been more careful.'

The newsletter blamed inadequate preparation and a lack of a proper handover between two doctors handling the case.

Medical workers should perform two 'time-outs' to double-check on the patients - including one just before the instrument goes into the ureter, it said. Staff should strengthen patient handover procedures to ensure doctors receive the proper critical information. And hospitals should encourage a 'speak up' culture among the surgical staff.

Two other incidents were reported in the newsletter.

In one case, a screw had not been removed from the fibula bone after an operation on a patient's left ankle to remove an implant and excise damaged tissue. Further surgery was needed to take the screw out.

In the other incident, a foreign object was found inside the pelvis of a patient two months after a tumour was removed from his bladder. The patient underwent more surgery to retrieve the object - a resectroscope, an instrument used in the previous surgery.