KNH staff reveal how bungled head surgery happened
For 23 years as a nurse, Mary Wahome has never experienced a medical error like the one she and seven other staffers working at Kenyatta National Hospital recently went through.
Hers, she told the National Assembly’s Health Committee on Wednesday, has always been a smooth shift every day she has reported to work until February 19, when under her care, the wrong patient was wheeled into theatre and underwent an unnecessary head surgery.
As Members of Parliament listened to the team of five doctors, two nurses and an anaesthetist who took part in the operation that saw Samuel Kimani operated on in place of John Nderitu, it became apparent that the problem started at the ward where there was confusion.
The team included Dr Michael Magoha, a junior neurosurgeon consultant who was on call that night of the surgery, Dr Nelson Okedi, who admitted the patient and recommended surgery, Dr Dave Mangar, a senior registrar, Dr Hudson Ng’ang’a, a fourth-year neurosurgeon registrar who operated on the wrong patient and Dr Mose Moraa, a third-year registrar who was assisting Dr Ng’ang’a.
Ms Wahome told the committee of inquiry that when she was informed to send the patient who needed surgery to theatre, the one who responded to the name “John Nderitu” was the one who was wheeled to the operating table.
Piecing together the events of that night, Ms Wahome said: “I was handling a call from customer care when I got another call asking me to send John Nderitu to theatre.”
In the theatre tray, she went on to say, there was only one file showing that only one male patient was needed.
“I walked into the ward and called out the name. Someone responded and I immediately prepared him, wrote his name on a tape and put it on the gown he was wearing,” she said.
All the while she had no idea that the man whom she had tagged and sent to theatre was not the right man.
This is because when the name was called out, according to Ms Wahome, Samuel Kimani responded as John.
“That night we had 61 patients against two nurses,” Ms Wahome added.
The mistake was however not noticed even after the surgeons in the theatre called the ward twice upon realising that the patient on the table was not Nderitu, but the nurses there confirmed the identity of the patient as being right.
On Wednesday, Dr Michael Magoha, who was third on call that day said: “I was consulted about the above patient on whether or not to do the operation and after reviewing the images and listening to the history of the patient, I agreed that the doctor proceeds with the procedure.
CONFIRMED PATIENT’S IDENTITY
“Thereafter, I was called on the 20th at 3am informing me that the three doctors were unable to locate the blood clot on the patient and I asked if they had confirmed the patient’s identity.
“I went to the hospital within 10 minutes of the call and upon corroborating what the doctors were telling me, I demanded for the ward to be called.
“I also checked that the patient had been labelled and that the patient’s identity was right. I didn’t see the clot despite position and site of Surgery being right as per the CT Scan,” Dr Magoha said.
It was only until the day the nurse who received the patient from casualty asked why the patient who needed surgery had not been operated on and was still in the ward.
“I got very confused when I heard about it. I did not know what to do and although my shift had ended, I went home extremely worried,” Ms Wahome told the committee.
During the committee hearing it became apparent that KNH does not have appropriate mechanisms for labelling patients as both the family of the patient who needed surgery and nurses confirmed that patients were not being tagged.
Nurses who accompanied Ms Wahome said lack of tagging in certain situations can lead to confusion.
At the same time, the team of medics in the theatre said that based on a medical scale (Glasgow Coma Scale) used to measure coherence of patients, at the time of preparing the patient for surgery, he was not coherent.
A Glasgow Coma Scale is a neurological scale, which aims to give a reliable and objective way of recording the conscious state of a person.
In this case the patient scored a 13 out of 15.