Surgical 'Never Event' Leads to $25M Lawsuit

Woman had stent put in wrong kidney at Vanderbilt University Medical Center
By Arden Dier,  Newser Staff
Posted Aug 8, 2019 9:35 AM CDT
Vanderbilt Doctors: Yup, We Operated on Wrong Kidney
This July 16, 2013 file photo shows Vanderbilt University Medical Center in Nashville, Tenn.   (AP Photo/Mark Humphrey, File)

Two doctors at Vanderbilt University Medical Center have admitted to implanting a stent in the wrong kidney of a woman who sued in March for more than $25 million. Carla Miller of Jackson, Tenn., died two months later, though her children are continuing with the lawsuit and will argue kidney issues contributed to their mother's death, attorney Brian Manookian tells the Tennessean. Miller was to receive a stent that ran from her urethra through her urinary system and into her left kidney. But doctors, apparently working from memory, admitted to implanting the mesh tube into Miller's right kidney. "It was an inadvertent mistake," Dr. Kelvin Moses, a Vanderbilt assistant professor of urology, said during a deposition last month. Urology resident Dr. Elizabeth Green said she'd mistakenly announced the wrong procedure site, adding an electronic whiteboard used to display patient information wasn't working.

After the error was discovered the next day in November 2017, the stent was removed and another implanted in the correct place. But in the lawsuit filed in March, Miller claimed damage to her urinary system that meant she would need dialysis from then on. Vanderbilt spokesman John Howser says there is "no evidence" the error affected Miller's health or contributed to her death linked to heart problems. The Tennessean describes the mishap as a "never event," which IFL Science explains is an event through should never have occurred because it's totally preventable. In addition to "wrong side" surgery, leaving an instrument in the body or implanting the incorrect surgical device are other surgical never events. (It's a bigger issue than you might think.)

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