Bad Staffing Led to Hospital DeathsMar 12, 2002 | AP
Inadequate staffing at New York City's Mount Sinai Hospital, including leaving 34 transplant patients in the care of an inexperienced first-year medical resident, contributed to the death of a man who donated part of his liver, a state report found Tuesday.
Michael Hurewitz died Jan. 13, three days after surgery in which he donated part of his liver to his ailing brother. Adam Hurewitz, a 54-year-old physician, survived the operation and reportedly is doing well.
"I am little bit aghast," State Health Commissioner Antonia Novello told the Times Union of Albany. "How can you leave 34 patients and donors to one resident?" Novello said Hurewitz's death "could have perhaps been avoided if there was more staffing."
Novello said she would order a suspension for at least six months of Mount Sinai's program of partial liver donations from live patients, as well as conduct an investigation into the hospital's pediatric liver transplant program.
The hospital voluntarily stopped adult live liver transplants on Jan. 15.
More live donor transplants are performed in New York than any other state, with the two biggest programs at Mount Sinai and at the University of Rochester Medical Center. Since 1988, Mount Sinai has performed more than 2,100 liver transplants, 178 with living donors because of the shortage of available organs.
Hurewitz's death was the first of a living donor, Mount Sinai officials said.
"Our investigation uncovered problems in care, and correcting them is our highest priority," hospital officials said in a statement.
Hurewitz, a Times Union reporter, donated about 60 percent of his liver to his brother, who had a degenerative liver disease.
"The transplant technique was perfect," Novello said. "It was the aftercare that was sloppy ... I call it a 'Space Odyssey' operation and a Third World follow-up."
The health commissioner said she will require the hospital to hire a consultant, at its own expense, to review all aspects of its liver transplant program.
The Health Department's 10-page report cites Mount Sinai for almost two dozen deficiencies.
Novello said she planned to pursue the maximum fine of $48,000.
Besides leaving care of its transplant patients to one "inadequately supervised and overburdened" resident, investigators also found the hospital had a shortage of nurses on the unit and that the patient's vital signs were neither taken nor recorded "as frequently as necessary" to monitor his condition.
The department also found that the surgeon who operated on Hurewitz, Dr. Charles Miller, never "saw the patient post-operatively," which is contrary to standard surgical policy. However, a hospital spokeswoman said Hurewitz was seen by a member of the transplant team.
The report said Hurewitz began showing signs of distress 24 hours before he died, including heart problems and later nausea. He began vomiting blood about two hours before he died, and an autopsy showed he had inhaled vomit caused by a bacterial stomach infection.