A nurse accidentally flushed away a healthy human kidney while the intended recipient awaited a life-saving transplant operation.
The organ, which had been donated by the recipient's brother, was lost and the transplant had to be cancelled after the mix-up at the University of Toledo Medical Center in the US state of Ohio last month.
The nurse claimed she was out of the room on a break when the surgeon told the staff that he had placed the kidney in a bag of chilled, protective slush.
Believing the bag contained waste, the nurse took it out of the operating room and flushed the contents down the chute of a dirty utility sink, AP reported.
None of the names in the case was released and the hospital would not say what happened to the woman who was denied the kidney.
The details were revealed in a review by the state for the federal Centers for Medicare and Medicaid Services (CMS).
Hospital administrative staff members interviewed have not determined how the nurse took the 59-litre bag of slush, meant to extend the kidney's viability, past several members of the medical staff without them noticing a problem, the report said.
The report said the hospital "failed to provide adequate supervision and communication", resulting in the kidney's disposal.
The surveyors also said that the hospital was not in compliance with CMS conditions of participation for transplant and surgical services.
CMS will authorise a full review of the conditions of participation for the hospital.
If it is found to be out of compliance, it could be terminated from the Medicare programme, a CMS spokesman said in an e-mail.
Procedures under evaluation
Hospital officials apologised for the incident and hired a Texas surgeon to evaluate its transplant procedures, but they have not released the results of that evaluation.
The incident has also led to a voluntary and temporary suspension of the hospital's living-donor kidney transplant programme.
Two nurses were suspended - and one was later fired and the other resigned - and asurgeon was stripped of his title as director of some surgical services.
A surgical services administrator was put on paid leave, but has resumed work.
The report said that the hospital has since enacted clearer policies to clarify communication between nurses who fill in for one another and to make sure nothing is removed from an operating room until the patient has been moved from it.
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