Monday, August 19, 2013


Policies & Procedures

Create BEFORE need


Lack of relevant policies and procedures is likely to cost the University of Toledo Medical Center (UTMC) at least US$25,000.

According to Lawyers and, a 30-year veteran nurse at UTMC was terminated for failure to stop another nurse from removing items from the operating room before the procedure had concluded. The complaining nurse claims she was also fired for violating policies on communications and logging out.

The story is that the plaintiff was working in the operating room (OR) with another nurse.

The other nurse left the OR for lunch, but, according to the article, failed to log out of the hospital computer system. Returning from lunch the nurse allegedly disposed of a kidney that was waiting to be transplanted.

The plaintiff contends

  • that she had not witnessed the removal of the items and was unaware they had been removed after the other nurse had returned from her break, and
  • that the policies and procedures to prevent such incidents were implemented days after the fact

Could policies and procedures - P&Ps - have prevented the Case of the Disappearing Kidney?

By themselves, unlikely. The article suggests the other nurse violated P&Ps (to log out of the hospital computer system) so at least one person disregarded published policies and procedures. It is possible, but based on the article likely NOT the case, that there was a policy and procedure to identify organs to be discarded.

In addition to the dismissed nurse’s suit, UTMC also is being sued by the family of the person who was supposed to receive the donated kidney.

If, then, P&Ps by themselves are not enough, what can be done to assure they are followed.

As with most things ERM, training, training, and more training, coupled with management flag waving to convince all personnel the reasons for, and the importance of, policies and procedures.

Having effected staff review, and comment on, relevant policies and procedures at least annually enhances awareness while giving the personnel a feeling of ownership.


If I wrote it, you may quote it.

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