Over Easter weekend, a 70-year-old semi-retired sportswriter with metastatic prostate cancer had a ureteral stent placed to relieve obstruction. The staff urologist who performed the procedure signed off at its conclusion.
The patient had significant pain following the procedure and was admitted overnight for observation. The resident on duty consulted by phone with the urologist. Subsequently, two radiology residents reviewed the post-procedure KUB (kidneys, ureter, bladder X-ray) to check the placement of the stent and (mistakenly) judged it to be properly placed. The next afternoon, a radiology fellow confirmed the residents’ (incorrect) judgment and the patient was discharged home.
On Monday morning, after two days of pain, the patient went to the hospital Emergency Department (ED). A repeat KUB suggested that the stent was not in proper position, and an abdominal CT scan was ordered to check the placement. Before the test was performed, the patient was assigned to a bed in the inpatient unit, but was kept in the ED to await his CT. During a nine-hour wait, the patient’s wife repeatedly complained to the ED staff that her husband was in severe pain. The patient received analgesics in response. No explanation was given to the patient or his wife for the delay.
At 6:00 p.m., the ED resident who had ordered the CT checked on the status of this patient. He discovered that the patient had been removed from the CT schedule because another patient with the same name had received a scan and been discharged. He informed the patient that this name mix up was the cause of the delay and scheduled an immediate CT scan.
The scan showed that the stent had perforated the patient’s ureter. A percutaneous nephrostomy was performed urgently under conscious sedation and a drain placed. Despite the sedation, the patient’s pain made positioning difficult, and he needed to be restrained. Near the conclusion of the procedure, the patient suffered a respiratory and then a cardiac arrest. He sustained severe brain damage.
At the request of the family, a conference was convened several days later to review the event. The radiology
and urology residents presented their part of his care, but could not agree on the chain of responsibility.
The patient died four months later. Although his prognosis had been poor prior to the perforation, his death was attributed to the complications related to his conscious sedation.
