Wrong-site kidney surgery was a 'mistake,' say Vanderbilt physicians

Two physicians admitted they mistakenly placed a medical device in the wrong kidney during a 2017 procedure at Nashville, Tenn.-based Vanderbilt University Medical Center, an error for which they are being investigated by the state health department, according to The Tennessean.

Kelvin Moses, MD, PhD, an assistant professor of urology at VUMC, and Elizabeth Green, MD, a urology resident at the hospital, admitted the error in depositions from July 2019. Dr. Moses said he reviewed the plan for the procedure beforehand but misremembered the details. Another Vanderbilt resident discovered the error the following morning, at which time Dr. Moses apologized to the patient and took responsibility for the error, according to the deposition.

Dr. Green said she was initially responsible for the error, since she announced the wrong procedure site before beginning the operation. VUMC surgical teams usually confirm patient information against an electronic whiteboard, but the whiteboard was malfunctioning at the time for an unknown reason, Dr. Green added. 

Carla Miller, the patient who underwent the mistaken procedure, filed a lawsuit against VUMC in March 2019. The lawsuit claims physicians implanted a stent on the wrong side of her body and into her right kidney, although the stent was supposed to go into her left kidney. Ms. Miller died in May 2019, but her family is continuing the lawsuit and says her kidney issues contributed to her death. 

VUMC conducted an analysis of the botched procedure immediately afterwards and instituted "corrective steps to ensure a similar error would not occur," according to spokesman John Howser. He said there is "no evidence" the mistake impacted Ms. Miller's health or led to her death.


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