Home >  News >  December, 2014

Veteran Surgeon Disciplined for Removing Prison Inmate's Wrong Kidney

Surgical team missed several opportunities to get it right.

Published: December 5, 2014

How can a wrong-site surgery happen? In the case of California urologist Charles C. Streit, MD, who last week was disciplined by the state medical board for removing a healthy kidney and leaving a cancerous one behind, the litany of contributing factors reads like an exercise in let us count the ways.

The board placed Dr. Streit, who's been practicing for 41 years, on probation for 3 years and prohibited him from supervising physician assistants during that time for the 2012 wrong-site surgery on a prison inmate.

The series of missteps began when a member of the surgical team left CT scans behind in an office. At that point, Dr. Streit chose to rely on his memory and paperwork that turned out to be wrong, instead of using ultrasound to verify the location of the tumors, says the board. Additionally, although no time out was done, the nurses and anesthesiologist told state inspectors that the patient gave them wrong information. One nurse said she doubted the patient, but that when she double-checked the (incorrect) paperwork, it seemed to verify what the patient was saying.

Ultimately, says the board, "voluminous and unambiguous data" was available to Dr. Streit, and the mistake "represent[ed] an extreme departure from the standard of care." St. Jude's Medical Center in Fullerton, Calif., where the surgery took place, last year was fined $100,000 by the department of public health, says the Orange County (Calif.) Register.

The patient, a 59-year-old inmate at the Terminal Island Correctional Facility in San Pedro, Calif., required further surgery, says the board, thereby "putting [his] future renal function in jeopardy."

Calls by Outpatient Surgery Magazine to Dr. Streit and to the lawyers who represented him in the hearing were not returned.

Jim Burger

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