A neurosurgeon has been suspended for opening up the head of the wrong patient in one of the worst cases of medical malpractice to become public at Kenya’s top hospital.
Two men had been wheeled into Kenyatta National Hospital (KNH) unconscious last Sunday.
One needed head surgery to remove a blood clot in his brain while the other only required nursing and medication to heal a trauma swelling in his head, medically known as closed head injury.
However, a horror mix-up of identification tags saw the wrong man wheeled into theatre and his skull opened.
Doctors did not realise the mistake until hours into the surgery, when they discovered there was no blood clot in the brain of the man sprawled on the operating table.
They had cut open the head of the wrong patient in a dizzying case of medical malpractice that once again casts the spotlight on the country’s biggest referral hospital.
The mix-up also raises questions about pre-surgery procedures in Kenyan hospitals, especially on how to ensure the right patient is operated on the right place.
It also calls to question doctors’ lack of commitment to their patients to ensure they receive the care they need to get well.
The Daily Nation, which investigated the scandal since Wednesday, will not publish details of the patients out of respect for their privacy and because it was not clear on Thursday if their families had been informed of the operation.
Thursday evening, hospital management threw out this reporter by dramatically having security guards escort her out of the premises for making enquiries about the incident.
In an effort to limit the damage following our enquiries, the hospital’s chief operating officer Lily Koros issued a statement announcing the suspension of four medics who were at work on the fateful night.
They included the neurosurgeon, the ward nurse, theatre receiving nurse, and the anaesthetist.
“The management has suspended the admission rights of a neurosurgery registrar and issued him with a show-cause letter for apparently operating on the wrong patient,” Ms Koros said.
The fact that Ms Koros was referring to the operation as “apparent” is probably an indication that the hospital was unwilling to publicly admit the error, and also that some of its procedures may have put the welfare of patients at risk.
She did not disclose the identity of the patients, only saying that the hospital will “advise on the cause of action to be taken”. The doctor’s suspension ends Friday.
The patients were received and both admitted in the hospital’s Ward 5A, which houses general surgery and trauma patients without fractures.
Patients wear name tags on their hospital gowns in this ward and investigations will look into how the two were given the wrong tags.
The tags are the patient’s only method of identification.
It appears in this system, the surgeon will have no contact with the patient, waits in the theatre, and follows the information in the files to carry out critical surgery.
“The staff in theatre had no way of telling they were operating on the wrong patient because he was unconscious,” a source, who requested anonymity because of the sensitivity of the matter, said.
“Besides, the file details and patient label tallied.”
The team only realised the mistake more than two hours into the operation after opening the head of the wrong patient, only to find a swollen brain but no blood clot.
After consulting a senior neurosurgeon on call, the operating doctor was instructed to proceed no further, clean up the area and close the head.
The doctor examined a CT scan of the patient and his file before recommending surgery.
Both showed that there, indeed, was a blood clot in his head.
However, the scan was from the wrong patient and the team did not discover the mistake until after the surgeon was halfway into the operation.
In a miracle of some sort, the Nation was informed that both patients were in good condition, and that the one who had a clot might not undergo surgery because he had improved significantly.
Few medical errors are as vivid and terrifying as those that involve patients who have undergone surgery on the wrong body part, undergone the incorrect procedure, or had a procedure intended for another patient.
These “wrong-site, wrong-procedure, wrong-patient errors” (WSPEs) are rightly termed “never events” — errors that should never occur.
Wrong-site surgery may involve operating on the wrong side, as in the case of a patient who had the right side of her vulva removed when the cancerous lesion was on the left, or the incorrect body site.