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Awry MOI surgeries: Team blames medics
2007-12-22 08:38:36
By Felister Peter
The commission formed to investigate the circumstances that led to the recent twin surgeries at the Muhimbili Orthopedic Institute (MOI) that went awry has blamed the debacle on irresponsibility by medical practitioners.
Health and Social Welfare minister David Mwakyusa unveiled the findings of the team at a news conference in Dar es Salaam yesterday. He formed the commission two weeks ago.
The minister said the medical practitioners involved in carrying out the operations flouted both professional and administrative procedures.
Generally, he explained, Standard Operation Procedures (SOPs) were not applied while preparing the two patients for surgery on November 1, 2007.
Following the findings, Prof Mwakyusa has instructed the MOI board of directors and the Tanganyika Medical Council to take appropriate disciplinary measures against all those confirmed to be behind the mess.
He gave the two bodies less than a week to implement the order.
He said the measures would include immediate termination of contracts, replacement with other qualified personnel, cancellation of doctors’ licences, and summary dismissal.
The committee reported that the list of patients lined up for surgery on the fateful day was prepared by an auxiliary nurse and was, surprisingly, not channelled through the chief operating doctor as required by medical procedures.
The auxiliary nurse listed Emmanuel Didas among the patients to be operated on while he was already being discharged since October 26, 2007, according to the minister.
The committee found that Didas remained in his ward because doctors had not done the daily patient rounds up to October 30, 2007. He finally had head surgery on November 1, 2007.
``Emmanuel Didas wouldn`t have undergone a head operation if the doctors` daily patient rounds were done. He was discharged a week earlier and told to return for a left leg operation after six weeks,`` elaborated Prof Mwakyusa.
He said the mandatory pre-surgery patient identification exercise was not done and both doctors and nurses ``indolently`` used the single name `Emmanuel` to identify the two patients involved in the mixed-up operations.
The minister said a nurse made both patients take valium in preparation for operation but without having consulted a doctor first. The excuse given for the anomaly was ``to save time``.
The committee further reported that on regaining consciousness after having undergone a leg operation instead of the head surgery he was in hospital for, Emmanuel Mgaya told a nurse in the ward that he was not Emmanuel Didas.
Didas said had the nurse on duty cared to listen to him and acted accordingly, he wouldn’t have undergone a leg operation, it added.
Mgaya was a secondary school student from Iringa Region and has since died, apparently from complications due to the head surgery he later had.
The committee reported that the nurse refused to listen to Mgaya`s complaints, saying Didas` remarks were made under the influence of the valium he had taken and could not have been taken seriously.
The committee reported that the doctors who operated on the two patients are confirmed professionals but they were not attentive or careful enough while performing their duties that particular day.
Prof Mwakyusa said a total of 12 MOI members of staff were involved in the bungled surgeries - two specialist doctors, three auxiliary doctors, an anesthesiologist, two nurses dealing with the administration of valium, two nurses helping in the surgery room, and two ward nurses.
He subsequently gave the MOI board of directors two weeks from yesterday to act on all the errors discerned and the recommendations of committee.
The board should also ensure that it strengthens its administrative team and punish all those involved ``in one way or another`` in performing the surgeries, he added.
He said all the doctors and nurses involved would be questioned by the Tanganyika Medical Council, the action to be taken against them depending on how the council would deem appropriate.
On November 1 this year doctors swapped the two patients, making them undergo surgery for ailments they were not suffering from.
Dar es Salaam-based motorcycle mechanic Didas took the head knife meant for Emmanuel Mgaya, who underwent a knee operation instead.
Mgaya was referred to the Muhimbili National Hospital from Kibena hospital in Njombe after developing a nagging headache.
Doctors recommended that he undergo a head operation in mid-November.
Mwakyusa dumped a report handed to him by a first committee formed by the MOI administration, saying it had left out ``some important issues``.
He added, however, that the aim of picking a new probe team was not to prejudice anyone but to enable the government to rule more wisely on the matter.
The team he formed was chaired by Prof William Mahalu, a neurosurgeon from Bugando Hospital in Mwanza, and did not involve any member of the Muhimbili National Hospital or MOI staff.
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