Man dies after doc takes lunch during kidney op


Online: http://www.thelocal.se/43048/20120906/

A 72-year-old man having a tumour removed from his kidney died after the
chief anesthetist and nurse took a lunch break in the middle of the surgery.

The incident, which took place at the Lidköping
<http://www.thelocal.se/tag/lidk%F6ping>  hospital, has prompted stinging
criticism from Sweden's National Board of Health and Welfare
(Socialstyrelsen).

The 72-year-old went under anesthetic at 10.45am on the day of the
operation, which took place in January 2011.

At noon sharp, the head anesthetist left the operating room to go for lunch.
Fifteen minutes later, the head nurse anesthetist also left the patient and
went for lunch.

No other anesthetist was called in to take over responsibility for the
doctor who was on his lunch break.

And while another nurse was brought in to cover for the nurse anesthetist,
the nurse who arrived came from the orthopedic ward and wasn't familiar with
the respirator to which the 72-year-old was attached.

Suddenly, the patient started hemorrhaging and his blood pressure started to
drop, sparking a "chaotic" situation.

As the patient's condition became critical shortly before 1pm, the
substitute nurse tried desperately to reach the lunching anesthetist, but to
no avail.

When the doctor and the primary nurse anesthetist returned to the operating
room, they discovered that the patient's respirator had been turned off,
leaving him without oxygen for approximately eight minutes.

Despite immediately starting resuscitation efforts, doctors were unable to
revive the man, who had suffered irreparable brain damage and died several
weeks later.

The man's daughter subsequently reported the incident to the health board,
which on Tuesday issued a harsh critique of the hospital's procedures.

"The operational planning, which allowed for the responsible doctor and
nurse to take lunch breaks at the same time without any other doctor taking
responsibility for the patient, entails taking an unacceptable risk," the
agency wrote in its findings.

The agency also found fault with the fact that the doctor wasn't reachable
by phone, as well as with the decision to hand responsibility for a
high-risk patient with a single nurse who lacked sufficient knowledge of the
equipment in use during the operation.

"The National Board of Health and Welfare finds, however, that the
operation's lack of organization as well as the chaotic situation which
occurred was the underlying causes behind the misjudgments and insufficient
care," the agency wrote.

The Local/dl

 

 

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