Lessons From A Lost Kidney
Last summer in Toledo, Ohio, Susan Fudacz was waiting for a kidney being donated by her younger brother, Paul Fudacz, Jr. They were a perfect match and Susan was excited to get a new lease on life with her brother’s gift.
When Susan woke from anesthesia, she noticed that she had no incision. It turns out that a nurse mistakenly tossed the organ that was sitting in a temperature controlled slush machine before it could be transplanted.
The surgical nurse who was to be part of the team left on her lunch break and her place was covered by the circulating nurse. When the surgical nurse returned from her break, she thought the kidney was medical waste and, therefore, discarded it. With that, the kidney unfortunately was unable to be used.
It was a shame how the media vilified the nurses. I’m not saying that what the nurse did was right, but certainly there were system problems that allowed this event to occur.
First, according to the news articles, the nurse who left on break did not give proper report to the circulating nurse who covered for her. There were no policies and procedures in place to prevent this situation.
The nurse who discarded the slush thought the kidney was in the recipient’s room because that is what usually happens in this type of scenario.
The lessons from this story: communicate, communicate, communicate! Never assume! Always ask!
Also in the room at that time were a physician and scrub nurse who should have seen the nurse walking out with the slush and the kidney but never said anything.
In addition, the usual process for emptying the slush machine was not followed as it is usually done by perioperative tech or a surgical scrub tech instead of the nurse.
Until after this event occurred, there was no policy in place at the facility for when a patient is handed off to another nurse and what communication must take place.
Just to let you know what has happened since this incident in August of 2012, Susan did receive a kidney the following November. Regardless, Susan and her family filed a lawsuit this past July against the facility where the events occurred.
Again, always make sure that your facility has policies and procedures regarding communications when you go onto and return from break. More importantly, make sure you know your facilities policies and procedures. If you see something that does not look quite right, say something! And, if you are not sure of something, don’t assume, always ask!
