Nearly three years after removing the wrong kidney from a federal inmate with cancer, an Orange County surgeon was handed down his punishment by the Medical Board.of California—three years probation.
Dr. Charles Coonan Streit admitted that he erred in February 2012 when he removed the right kidney of a 59-year-old inmate from the Terminal Island Correctional Facility. The man had been diagnosed with a tumor on his other kidney four months earlier.
Streit made the mistake, at St. Jude Medical Center in Fullerton, when he chose to operate from memory and what turned out to be faulty paperwork after CT scans were mistakenly left in the offices of one of the surgical team’s doctors. The board said the goof was “an extreme departure from the standard of care.”
That standard required a review of image scans before slicing open the patient. When the CT scans were found to be unavailable, the doctor could have done a renal ultrasound to locate the mass. He didn’t. The diagnosis had been incorrectly written down as a cancerous right kidney when the patient was admitted to St. Jude. The patient was originally tested and diagnosed at Long Beach Memorial Medical Center.
In addition to probation, the urologist is required to enroll in UC San Diego School of Medicine’s wrong-site surgery course with 60 days. Streit can no longer supervise physician assistants. St. Jude, where Streit remains on staff, was fined $100,000 by the California Department of Public Health (CDPH).
Streit had plenty of help botching the operation, according to a report (pdf) by the CDPH. Two nurses and an anesthesiologist told investigators that they thought the right kidney was the target. They said the patient thought it was the right one and medical records indicated that was the diseased organ. But the one piece of information that would have definitively identified the cancer location was sitting in a doctor’s office elsewhere.
“The hospital failed to follow their policy and procedure to have relevant images and results properly labeled and displayed prior to a patient’s surgery,” the report said. “The failure resulted in the removal of the wrong kidney.”
The patient underwent another surgical procedure to have the cancerous kidney removed, but life without kidneys is not pleasant.
Hospitals screw up a lot: instruments are left in patients; wrong medications are dispensed; patients fall out of bed after being improperly restrained; and some folks are misdiagnosed. But the Joint Commission Center for Transforming Healthcare characterized wrong-site surgeries as being “rare” in an August report (pdf).
The center said that 463 incidents of “wrong-patient, wrong-side, wrong-procedure” operations were voluntarily reported nationally from January 1, 2010, to December 31, 2013. But they suspect the real number is “much higher, perhaps as often as 50 incidents per week in the United States.”
That might sound low for a nation of 317 million people if it’s not your only healthy kidney being inadvertently removed.