Becker's Clinical Quality & Infection Control

6 INFECTION CONTROL & PATIENT SAFETY Wrong-site kidney surgery was a 'mistake,' say Vanderbilt physicians By Anne-Marie Kommers T wo physicians admitted they mistaken- ly placed a medical device in the wrong kidney during a 2017 procedure at Nashville, Tenn.-based Vanderbilt University Medical Center, an error for which they are being investigated by the state health depart- ment, according to e Tennessean. Kelvin Moses, MD, PhD, an assistant pro- fessor of urology at VUMC, and Elizabeth Green, MD, a urology resident at the hospital, admitted the error in depositions from July 2019. Dr. Moses said he reviewed the plan for the procedure beforehand but misremem- bered the details. Another Vanderbilt resident discovered the error the following morning, at which time Dr. Moses apologized to the patient and took responsibility for the error, according to the deposition. Dr. Green said she was initially responsible for the error, since she announced the wrong procedure site before beginning the opera- tion. VUMC surgical teams usually confirm patient information against an electronic whiteboard, but the whiteboard was malfunc- tioning at the time for an unknown reason, Dr. Green added. Carla Miller, the patient who underwent the mistaken procedure, filed a lawsuit against VUMC in March 2019. e lawsuit claims physicians implanted a stent on the wrong side of her body and into her right kidney, al- though the stent was supposed to go into her le kidney. Ms. Miller died in May 2019, but her family is continuing the lawsuit and says her kidney issues contributed to her death. VUMC conducted an analysis of the botched procedure immediately aerwards and insti- tuted "corrective steps to ensure a similar er- ror would not occur," according to spokesman John Howser. He said there is "no evidence" the mistake impacted Ms. Miller's health or led to her death. n Erlanger VP resigns over patient safety concerns: 'I can no longer in good conscience remain in my role' By Mackenzie Bean E rlanger Health System's vice president of patient safety and quality resigned July 12 amid serious patient safety and care quality concerns at the Chattanooga, Tenn.-based system, reported the Times Free Press. "I can no longer in good faith and good conscience remain in my role," Pam Gordon said in a July 1 resignation letter obtained by the Times Free Press. "This has caused me health issues and many sleepless nights," she con- tinued. "I am leaving employment to seek other opportunities that better align my professional passion and skillset." Ms. Gordon worked at Erlanger for two and a half years. Her departure comes nearly three months after the system's medical executive committee sent a letter to Erlanger's board of trustees, citing concerns over operation- al and patient safety issues. The medical staff issued a no-confidence vote directed at several executive leaders. In a statement to the Times Free Press, Erlanger said its external care quality and patient safety scores have "objectively improved" under Ms. Gordon's leadership. "We do wish Ms. Gordon well in her new position and look forward to evaluat- ing and assessing this important role at our health system," the hospital said. n 41% of parents would switch providers if practice treated unvaccinated kids By Mackenzie Bean A bout 4 in 10 parents said they would likely switch providers if their children's physician practice treated unvaccinated patients, according to the C.S. Mott Children's Hospital National Poll on Children's Health. Ipsos Public Affairs conducted the survey on behalf of the Ann Arbor, Mich.-based hospital, polling a nationally representative survey of parents in February 2019. Four survey findings: 1. Thirty-nine percent of parents said their child's primary care office has a policy requiring all children to receive recommended vaccines. 2. Twenty-four percent of respondents said their physician office permits unvaccinated children to use the same waiting area as other patients. 3. Forty-three percent of parents said they would want to know if the physi- cian practice treated unvaccinated children. Thirty-three percent would not want to know. 4. If the practice did treat unvaccinated children, 12 percent of parents said they'd be "very likely" to switch providers and 29 percent said they'd be "somewhat likely." n

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