AHRQ WebM&M: Morbidity and Mortality Rounds on the Web ► Two Wrongs Don't Make a Right (Kidney) Spotlight Case Commentary by John G. DeVine, MD

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web

Two Wrongs Don't Make a Right (Kidney) 

Commentary by John G. DeVine, MD

The Case

A 53-year-old man presented to Hospital A with abdominal pain and hematuria. Computed tomography (CT) imaging revealed a suspected renal cell carcinoma in the right kidney. He was transferred to Hospital B for surgical management.

All of the medical records from Hospital A documented a left-sided tumor—the wrong side. The CT scan from Hospital A was not available at the time of the transfer and repeat imaging was not obtained by the providers at Hospital B.

At the time of surgery, the surgeon was asked if the absence of an available image should preclude progressing with the surgery. He decided to proceed and, based on the available information, removed the left kidney.

The day following the surgery, the pathologist contacted the surgeon to report no evidence of cancer. The surgeon then reviewed the initial CT scan and realized his mistake. The patient underwent a second surgical procedure to remove the right kidney (which was found to have renal cell carcinoma). Having lost both kidneys, the patient was then dependent on dialysis, and because of the cancer, he was not a candidate for kidney transplant.

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