On July 27, a 77-year-old man underwent a heavy medical error in the urology department of Henri Mondor Hospital in Créteil (Val-de-Marne). Operated for a cancerous tumor, he was removed the healthy kidney instead of the sick kidney, according to the Radio France investigation cell. A extremely rare “side error” that could have had vital consequences.
Everything had taken place as planned
The intervention was expected. Complete ablation of the reached kidney (total nephrectomy) generally ensures a five -year survival rate of 90 to 100 %, according to the advance of cancer. Everything seemed to be planned. During the verification just before the intervention, the patient had confirmed his identity and specified the reached side. Despite this, the surgical team removed the opposite organ. The healthy organ. According to several hospital sources, specify our colleagues, the error could be linked to the scanner report.
Reoped in an emergency in another AP-HP hospital, his vital prognosis is not engaged, but he will now have to live with irreversible sequelae. His family filed a complaint.
Checks comparable to aviation
Patient safety is based on a series of compulsory controls, established in 2010 and inspired by aviation. Identity, operated side, available equipment, medical history: as many elements recorded in a “checklist” intended to reduce human errors.
A fact confirmed by our expert. “”We never decide an operation on the basis of a single exam “, recalled Dr Gérald Kierzek, emergency artist and medical director of True Medical in a similar case. “We verify several times the patient’s identity, the side concerned, and even in the block, the surgeon can request an extemporaneous analysis of the tissues. All these elements are there to limit the risks”.
But, he concedes, “There is a human factor and an error can always occur”. In these cases, a morbid-mortality review must be organized to understand the failure and prevent it from happening again.
One in three checklists is poorly applied
If this tool is recognized as a major safety lever, its application remains imperfect. According to the World Health Organization, its respect would avoid “30 to 50 % of medical complications and errors”. However, an internal report of the AP-HP indicates that in 2024, “one on three dysfunction“. Out of 194,000 interventions, 58,200 patients therefore did not benefit from optimal security and 2,000 interventions left no trace of checklist. According to the survey published today, testimonies of caregivers confirm these flaws.
“”We check the checklist, even if it is not done “deplores an operating room nurse.
“”It is not in the interest of the patient “. According to her, certain stages are carried out mechanically, sometimes in the absence of surgeons.
For the High Authority for Health, more than 90 % of serious undesirable events are linked to the misuse of the checklist. But in France, its application is based on the “culture of professionals” and not on a regulatory obligation. A situation denounced by Claude Rambaud, vice-president of France Asso Health:
“”It doesn’t work. We believe that a system which stands out for law and be criminally and civilly opposed, as in security anesthetic security.“.
The association also specifies: obtaining its checklist, at the same time as the medical file, in the event of doubt, is now possible thanks to a recent decision of the Council of State.
The AP-HP reacted to the publication of this report, specifying that “On nearly 200,000 surgical interventions, the checklist was not drawn in the information system in 0.01 % of cases and 30 % of the traced checklists are incomplete, in the sense that at least one of the 25 control points has not been informed, mainly, for 87 % of anomalies, on post-operative items“. The institution aims to be reassuring by concluding in its press release by:”If these results, shared with operating room managers, underline a significant margin for the progress of traceability,, there Quality of care and patient safety are fully ensured. For the year 2024, on all surgical interventions at the AP-HP, 60 have been the subject of a serious adverse event declaration, mainly relating to complications outside the operating room, the causes of which are often multiple “.