A federal inmate entered surgery in February 2013 thinking he would soon be free of his cancerous left kidney. When he emerged, he had lost his healthy right one instead. It was a mix-up that could have been easily avoided had California surgeon Dr. Charles Coonan Streit examined radiology and diagnostic tests, images, scans and pathology reports, as is standard protocol, the California Medical Board said last week. Instead, he relied on his memory as the patient's CT scans were left behind at another doctor's office, the Orange Country Register reports. The operation put the inmate's "future renal function in jeopardy" and prompted another surgery, the board said.
It turns out the paperwork that Streit had showed the patient was admitted to St. Jude Medical Center with cancer in his right kidney. Nurses and an anesthesiologist said the patient himself said the right kidney was the problem. However, the medical board said Streit, now on a three-year probation, could have performed a renal ultrasound to reveal the tumor's location. "It was our failure to follow our protocol regarding displaying the patient’s diagnostic images that ultimately resulted in this error," said a rep for the hospital, which was fined $100,000. The medical board said it was Streit's "sole obligation" to review those images. (A surgical mix-up may have spread a rare brain disease.)