Vanderbilt doctors operated on wrong kidney, claims $25.5M lawsuit

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Abstract:

A Tennessee woman sued Vanderbilt University Medical Center on Tuesday, alleging the hospital operated on her wrong kidney during a surgery — a mistake so rare and preventable that medical experts call it a "never event."

Carla Miller, of Jackson, claims in her lawsuit that Vanderbilt doctors were supposed to implant a small mesh tube extending from her left kidney through her urinary system to her bladder during a surgery in November 2017. Instead, doctors mistakenly implanted the tube in her right kidney, then ran it through the wrong half of her body, according to a lawsuit filed in Davidson County Circuit Court on Tuesday.

As a result of the error, Miller's urinary system was damaged and she now needs dialysis for life, said attorney Afsoon Hagh. Miller also had to undergo a second surgery to remove the mesh tube and place it on the correct side of her body, the lawsuit states.

This lawsuit comes during a damaging stretch for Vanderbilt, the largest and most renowned hospital in Tennessee. Last month another lawsuit alleged that a Vanderbilt patient died when an unsupervised resident botched the routine procedure of placing a central line in her neck. And earlier this year a former Vanderbilt nurse was criminally indicted for accidentally giving a patient a lethal dose of vecuronium, a paralyzing drug used to execute patients on death row.

All three of the Vanderbilt incidents allegedly occurred between April and December of 2017 but only became public knowledge in the past six months.

https://www.tennessean.com/story/news/health/2019/03/19/vanderbilt-wrong-kidney-surgery-never-event-lawsuit-nashville/3108467002/

She's on dialysis for the rest of her life. What's going on at Vanderbilt?

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This is so insane!! I am about to start Nursing school in May and I was just curious for those nurses out there working in the field.. how do things like this happen?

I’m not judging or being condescending or anything like that.. I’m just genuinely curious. Is it high patient to nurse ratios? Improper training? It’s scary knowing that one mistake on your part can cost a person their life.

How can mistakes like these be avoided? Asking to tuck in my learning binder for when I eventually enter the field ?

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30 minutes ago, StudentGBC13 said:

How can mistakes like these be avoided?

Always, always, always do your 5 rights. I cannot emphasize this enough. If you aren't familiar with a med look it up (both the generic and the brand name) BEFORE you give it. Even after you've been a nurse for decades. Treat every patient as you would want your mom treated (or your dad if you don't like your mom.) If you're feeling rushed and overwhelmed STOP, take a deep breath and review your next step to make sure you aren't missing something.

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28 minutes ago, Wuzzie said:

Always, always, always do your 5 rights. I cannot emphasize this enough. If you aren't familiar with a med look it up (both the generic and the brand name) BEFORE you give it. Even after you've been a nurse for decades. Treat every patient as you would want your mom treated (or your dad if you don't like your mom.) If you're feeling rushed and overwhelmed STOP, take a deep breath and review your next step to make sure you aren't missing something.

Thank you so much for the advice !! This makes so much sense to me. In my Kinesiology labs where we would run tests on clients and things like that our profs always told that if you don’t know something, or if you can’t do a calculation off the top of you head, take a second, and look it up or do it properly. It’s always better safe than sorry. I will definitely take this with me !! Thank you ?

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Also, if you every have questions or feel uneasy about something, seek help from your peers or a supervisor. Always err on the side of caution! And always double, triple, etc etc etc check on 5 rights and surgical protocols.

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On 3/20/2019 at 6:37 PM, NurseBlaq said:

She's on dialysis for the rest of her life. What's going on at Vanderbilt?

I have every hope that the PTB at Vanderbilt will find her a quick transplant match, much like they did for the liver transplant of the incorrect blood type. That error was corrected in 3 days with a liver of the rare, but correct blood type.

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Specializes in Prior Auth, SNF, HH, Peds Off., School Health, LTC.

There’s something wrong with the story ....

even if the wrong-sided stenting somehow caused irreparable damage to that ureter.... which would be *really* unlikely—

how on earth would this mean that the woman would require dialysis for life???

Maybe she *might* need temporary dialysis *if* her other kidney weren’t functional.... but if that were the case it wouldn’t have needed stenting in the first place.

*If* the error happened as reported— that a stent (called mesh tube in the story) was placed in the wrong ureter, and damaged it (which is ironically what the stent is supposed to be helping avoid...), then the error could be remedied with a ureteroplasty of the damaged ureter and then stenting of both sides— the side that was originally supposed to be done, and a stent to allow healing of the rebuilt ureter.

Until such time as that could be accomplished, a nephrostomy tube could be placed (by an interventional radiologist— wouldn’t even need a trip to the OR) which would allow urinary drainage, preventing renal damage.

Worst case as I see it, (based on what was reported) if for some reason a ureteroplasty isn’t an option, then the patient has to live with a permanent nephrostomy/urostomy. Not dialysis. Not as long as even one of their kidneys are functioning.... i.e. the one that originally needed the stent.

Like I said.... something doesn’t add up with this story as reported.

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On 3/23/2019 at 5:26 AM, Duranie said:

There’s something wrong with the story ....

even if the wrong-sided stenting somehow caused irreparable damage to that ureter.... which would be *really* unlikely—

how on earth would this mean that the woman would require dialysis for life???

Maybe she *might* need temporary dialysis *if* her other kidney weren’t functional.... but if that were the case it wouldn’t have needed stenting in the first place.

*If* the error happened as reported— that a stent (called mesh tube in the story) was placed in the wrong ureter, and damaged it (which is ironically what the stent is supposed to be helping avoid...), then the error could be remedied with a ureteroplasty of the damaged ureter and then stenting of both sides— the side that was originally supposed to be done, and a stent to allow healing of the rebuilt ureter.

Until such time as that could be accomplished, a nephrostomy tube could be placed (by an interventional radiologist— wouldn’t even need a trip to the OR) which would allow urinary drainage, preventing renal damage.

Worst case as I see it, (based on what was reported) if for some reason a ureteroplasty isn’t an option, then the patient has to live with a permanent nephrostomy/urostomy. Not dialysis. Not as long as even one of their kidneys are functioning.... i.e. the one that originally needed the stent.

Like I said.... something doesn’t add up with this story as reported.

Her urinary system was damaged and her kidneys can't filter her blood, therefore dialysis.

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18 minutes ago, NurseBlaq said:

Her urinary system was damaged and her kidneys can't filter her blood, therefore dialysis.

But how? A simple stent placement even in the wrong kidney should not have caused any damage at all.

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6 minutes ago, Wuzzie said:

But how? A simple stent placement even in the wrong kidney should not have caused any damage at all.

Agreed. However, the article states the tube was extended throughout her urinary system. They placed it on the wrong side and through the wrong side of her system, and somehow it caused the system to fail. What it doesn't say is how long it was there and what actually caused the system failure. Therefore, I can't specifically give an answer to that. I can only infer maybe it was due to infection, her body attacking the mesh, her system was already weak, etc. I don't have a definitive answer but if her urinary system failed, dialysis would be necessary. Unless they did more damage than what's being reported and we're only getting a blurb of what actually happened.

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1 minute ago, NurseBlaq said:

Unless they did more damage than what's being reported and we're only getting a blurb of what actually happened.

I don't trust the media at all. What they are saying does not make sense. That is why I'm reserving judgment on the situation until some sort of official findings are released.

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