Perfect storm led to healthy kidney removal

Doctor failed to use second patient identifier in checking scan

ANKUR PARIKH, a 37-year-old urologist, logged into the medical records system at UMass Memorial Medical Center in Worcester and examined what he thought was a CT kidney scan that had been done on his 65-year-old patient who had blood in his urine. The scan showed the presence of a large tumor on the left kidney, which would explain the bloody urine. As a result, Parikh removed the left kidney.

But it was a case of mistaken identity.

The scan did not belong to Parikh’s patient, but to another patient who had the same exact name and who had the same exact CT scan done on him on the same day as Parikh’s patient.

The perfect storm of coincidences led to the removal of a healthy kidney from the wrong patient. The mistake occurred because Parikh failed to follow proper protocol when he logged into the medical records system. He accessed it by entering just his patient’s first and last name, and failed to use a second patient identifier such as date of birth.

 

The kidney removal, a procedure called radical nephrectomy, was performed in 2016 at St. Vincent’s Hospital, an affiliate of UMass Memorial Medical Center. It came to light publicly last week when the Board of Registration in Medicine released a consent order saying it had reprimanded Parikh for his actions. The board considers a reprimand to be a “severe form of censure.”

When the medical board reprimands a physician, other penalties are sometimes imposed as well. That did not happen with Parikh. He was not fined, he is being allowed to continue his surgical practice without being monitored by a senior colleague, and he is not being required to complete a relevant continuing education program.

Hospitals are required to inform state regulators when an adverse event occurs, but the consent order in Parikh’s case said the Board of Registration in Medicine learned of the incident from a whistleblower on the hospital staff. “This was preventable and needs to be investigated,” the unidentified whistleblower is quoted as saying in the consent order.

Officials at St. Vincent’s could not be reached for comment.

At various times between the initial office visit between Parikh and his patient and the evening before the surgery, Parikh logged into the UMass Memorial Medical Center system to view what he thought was his patient’s CT scan. But he accessed the system by using a tool that allows users to examine the images they recently viewed without having to reenter the patient’s identifiers.  As a result, Parikh kept looking at the wrong CT scan

Meet the Author
Just prior to removing his patient’s healthy kidney, Parikh observed that it did not feel as heavy as would be expected given the size of the tumor. Nonetheless, he proceeded with removing the kidney.

After it was all  over, Parikh was informed by a hospital pathologist that there was no tumor to be found on the kidney, which led to the discovery of the mistake, according to the consent order.