MPs shocked by KNH’s disregard for surgery checklist

Health workers at Kenyatta National Hospital missed basic but vital procedures before and during the operation, which resulted in the recent surgery mix-up — one of the worst cases of medical malpractice.

When the hospital staff and management appeared before the Health Committee on Thursday, it became apparent that some laid down, standard operating procedures, were not followed.

KNH chief executive officer Lily Koros, her deputy Bernard Githae (both currently on compulsory leave) and the board of management laid bare the gaps in the hospital’s standard operating procedures.

These included lapses in labelling patients admitted to the country’s largest referral facility.

Health Cabinet Secretary Sicily Kariuki also appeared before the Senate Committee on Health. She was hard pressed to explain why she suspended the two officials.

PATIENT TAGGING
While before the committee, the 14-member team of KNH’s board was at pains to explain how the documents presented before the Members of Parliament lacked a section on the need to properly tag patients.

“Labelling of patients is nowhere in these standard operating procedures of patient admission. It means that it is not even part of your procedures to begin with,” Ms Sabina Chege, who chairs the committee, said.

This seems to have been the root cause of the problem, even as Dr Githae, KNH’s director of clinical services, admitted that the pre-operative checklist that ought to have been filled by the ward nurse, anaesthetist and surgeon before proceeding with the operation was not filled.

“There was a problem in patient identification at the ward as both patients did not have tags. Labelling is usually done at the ward level, but we have now recommended it be done at the casualty department,” Dr Githae, who has served at KNH for the past 27 years, said.

CHECKLIST
Among the things that the nurse, anaesthetist and surgeon should look out for in the pre-operative checklist are: The patient’s name, procedure, and where the incision will be done.

Another standard procedure went wrong during the nurses shift change.

According to one of KNH’s board members, the team of nurses working the day shift failed to properly hand over to the night shift team.

Also, the committee was told, a nurse who was not present during the hand over ended up wheeling the patient to the theatre.

“When a change of shift occurs, reports with intricate details of individual patients should be handed over to the incoming team. The team should also meet the patients and know about those who need special care,” Ms Rosemary Awendi, the deputy director, said.

CHALLENGES
However, she added, circumstances under which nurses work at KNH can at times lead to errors.

In this case, the nurse who took the wrong patient to the theatre relied on the patient’s response as she was not present during the hand over.

At the Senate, the Health CS submitted a report containing preliminary findings of the surgery mix-up.

The report cites the failure to tag patients on admission, congestion at the facility, shortage of manpower, long working hours and non-adherence to standard operating procedures as the main causes of the unintended surgery.

NURSES
Ms Kariuki revealed that about 60 neurosurgical cases were reviewed at the Accident and Emergency Department on the material day yet only three nurses were on night duty in the ward attending to 47 patients.

She added that inadequate staff capacity contributes to long hours of work at KNH.

She said disciplinary action had been taken against a Dr Ng’ang’a, the neurosurgical registrar who performed the operation, by way of withdrawal of his admission rights pending investigations because of lack of doctor’s return notes when Mr John Mbugua was returned to the ward.

MEDICAL HISTORY
The CS’s response triggered a storm, with senators saying the mix-up could have been reduced by labelling.

Also, such delicate operations require details on the patient’s medical history.

After reading the preliminary report, committee chairman Michael Mbito challenged the CS to explain the role of the CEO and Director of Clinical Services, who have both been suspended pending investigations, considering that the mistake was a technical one.

“The preliminary findings neither mention the CEO nor the director of Clinical Services. On what basis did you sack her?” Mr Mbito (Trans Nzoia senator) asked.