A surgeon at Saint Vincent Hospital unnecessarily removed a patient’s kidney because he relied on the test results of another patient with the same name, according to public health inspectors who found serious safety lapses at the hospital.
The federal Centers for Medicare & Medicaid Services threatened to terminate Saint Vincent from the Medicare program on Dec. 12 if the Worcester hospital does not put in place improvements, according to a letter last month from the agency to hospital chief executive Steven MacLauchlan.
The agency also faulted the hospital for not taking immediate and thorough steps to address problems it found in its own internal investigation.
Medicare’s investigative report said the patient was scheduled for surgery July 20. The surgeon checked a CT scan prior to surgery, which showed a large tumor present on the left kidney.
But it turned out the scan was for another patient with the same name. The surgeon apparently failed to use a second piece of identifying information, such as a birth date, to connect the CT scan to the correct patient, the report indicated. The medical record for the patient who had the surgery did not contain a CT scan, the report said.
The surgeon discovered during the operation, after he had taken out the kidney and sent a sample to the pathology lab, that it was tumor-free. The report did not identify the patient or the surgeon.
The state Department of Public Health conducted the inspection in conjunction with Medicare over five days in August. “The department expects the hospital to take immediate steps to address the findings of the investigation and will continue to monitor follow-up through unannounced inspections,” the agency said in a statement.
Saint Vincent submitted an improvement plan but investigators have not yet returned to verify that the changes were implemented. The plan includes educating operating room staff about how to correctly identify patients and ensuring all test results are on hand before a surgery can proceed.
“We are working to implement enhanced safeguards as identified in the CMS survey, including additional verification steps with physicians,’’ said a statement from Saint Vincent. “This was a deeply unfortunate situation and we will take all steps necessary to prevent it from happening again.’’
When the surgical error first became public in August, the hospital said the patient misidentification “took place outside of our hospital and did not involve our employees’’ and that staff “followed proper protocols.’’
The Medicare report mentions that a physician referred the patient to the surgeon but does not say whether the physician also made a mistake and read the wrong CT scan.
But inspectors found lapses at the hospital, including the fact that operating room computers displayed patients’ names but not their birth dates. While this problem was discovered during the hospital’s internal investigation in late July, it was not corrected until two weeks later during the inspection, the Medicare report said. It also said the hospital did not plan to thoroughly investigate why the patient’s medical record was missing a CT scan, and that during the inspection one-third of the 90-member surgical staff had not yet attended a education session on patient identification.
Investigators said the hospital failed to implement improvement plans in three other instances where patients were not identified correctly.
Liz Kowalczyk can be reached at firstname.lastname@example.org.