Health

State, feds find muddled records lead to Saint Vs kidney mistake. \\ By Susan Shalhoub ORGAN FAILURE W hile denying that it was at fault in what led to the removal of an organ from the wrong patient over the summer, Saint Vincent Hospital in Worcester could see Medicaid and Medicare payments terminated in December if patient safety deficiencies remain, according to state officials. According to reports from the state Department of Public Health (DPH) and federal Centers for Medicare and Medicaid Services (CMS), the fallout stems from a July 20 sur- gery, where an error resulted in a kidney being removed from the wrong person at Saint Vincent. The surgeon — who had been working from a CT scan image of a tumorous kidney — was told from pathology results that the kidney was, in fact, healthy. 16 HEALTH • Winter 2016 What led to this error was, in some ways, a per- fect storm in terms of coincidence, and a cautionary tale for the Central Massachusetts healthcare indus- try, about how the potential for such errors exists. It highlights the importance of locked-down patient safety procedures and accountability. Logistics at play The patient who had the kidney removed and the patient who should have had a kidney removed had the same name, and the same month and day of birth. Additionally, the DPH and CMS report says that the two patients had imaging procedures done on the same date. The first patient's CT scan was missing from his or her medical record, but the wrong one was there instead, according to the DPH and CMS. According to the state and federal investigators' official report, the fact that the CT scan was missing was not unusual. A pre-admission testing unit nurse at Saint Vincent's said that staff have had difficulty getting reports and documents from doctors' offic- es. The report quotes this person as saying the issue had been ongoing "for a while, years." A Saint Vincent associate medical director was I L L U S T R A T I O N / D R E A M S T I M E . C O M

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