KNH boss blames fatigue of staff for surgery mix-up

Overwork could have caused the debacle that led to the wrong patient undergoing brain surgery, the Kenyatta National Hospital boss said yesterday.

Suspended chief executive officer Lily Koros said a serious staff shortage was causing fatigue among the workers and that this could have caused the mix-up in the theatre.

Appearing before the National Assembly Health Committee yesterday, Ms Koros said although a full report by the medical board would give a clearer picture of the situation, KNH was running almost on the rims in terms of staff numbers.

She said the nurses were the most affected and that the hospital needed 800 more nurses to boost its current 1,500.

61 patients

Mary Wahome, a nurse involved in the case, said she and her two colleagues were handling 61 patients on the day of the mishap.

The hospital's board told the committee that the surgeon who carried out the operation had worked for 24 hours without a rest.

Wahome told the committee that apart from attending to patients, she was also responsible for answering external calls and consulting with patients’ families. She explained that this was the reason she had Simon Kimani wheeled into the theatre for brain surgery instead of John Nderitu.

"It was just total confusion," she said.

The CEO was criticised for 'not being handy in her work' and putting too much trust in other people to handle the crisis.

Koros told the committee chaired by Murang'a Woman Representative Sabina Chege that Kenyatta needed 172 more doctors and up to 275 security personnel. The ratio of nurses to patients is supposed to be 1:5 but the facility is operating at 1:40.

She said the new plan was to operate at a ratio of 1:15. On the issue of patients not being tagged, Koros said on the day of the incident, there were 3,200 identification bands for adult patients and 1,100 for children, "but none of the staff had ordered them".

Her deputy, the director of clinical services, Dr Bernard Githae, who had appeared earlier, confessed that it was not the facility’s practice to give patients name tags at the Accidents and Emergency Unit, "but we are working to change all that".

“There is a possibility that the team could have been fatigued or just that there was similarity in tagging of the patient. But we have to wait for the report,” said Koros.

The board said the seven-member team in the neurosurgical department was made up of registrars (students undertaking their post-graduate studies).

The registrars, Koros said, saw their own patients in Ward 4C and also did rounds in other wards where they had patients.

"The reason we have made it to this level, I would say, is by God's grace. Even our equipment has been stretched as KNH now operates as a level One to level Six hospital instead of referral facility," said Koros.

She added: “I am not saying that I acted perfectly, maybe there was a loophole, but I am willing to learn. I have to agree the learning has been quite expensive and painful.”

The registrars, the committee was informed, spent 80 per cent of their time working without pay and only 20 per cent to study. They are the ones also responsible for about 80 surgeries a day at the hospital on weekdays and 30 during weekends.

“Because of their long working hours, to some extent that could be a relevant factor that could contribute to (medical) accidents,” said Calvin Nyachoti, the KNH corporate secretary, who accompanied the KNH board members.

His argument, however, was dismissed by some of the legislators in the committee including Matungulu MP Stephen Mule, who said the mistake seemed to lie with the nurses who identified the patient for surgery.

Standard procedure

According to the standard operating procedure of Kenyatta, the first person to identify the patient was the ward nurse. The committee vice chairman, Dr Swarup Mishra, said in normal circumstances, the surgeon did not come into contact with the list of patients.

Earlier, Health Cabinet Secretary Sicily Kariuki told senators that the KNH board had sent Koros on compulsory leave pending investigations into the incident. Ms Kariuki said she only announced the agreement reached by the board to send the CEO on leave, but did not suspend her.

“I attended a crisis meeting at KNH presided over by board members. They decided to undertake a probe into the matter and found it necessary to send the CEO on compulsory leave to facilitate impartial investigations,” she said.