In December 2022, 78-year-old Nachshon Har-Zvi passed away after a tool malfunctioned during a complex cardiac catheterization operation at central Israel's Rabin Medical Center.
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A report by Dutch giant Philips, revealed Wednesday by Ynet, showed that several days before the procedure, a main component of the device underwent a repair.
According to the manufacturer's report, which produces the imaging device that was used by the surgeons and failed suddenly, a non-original and unrecognized part was installed during the repair instead of replacing the entire device, thus resulting in the malfunction that led to Har-Zvi's death.
Healthcare provider Clalit Health Services, which owns the hospital, and the Health Ministry launched a joint probe into the incident. However, almost five months later, its conclusions have not yet been published.
Senior healthcare system officials who are familiar with the details of the probe claim that the reason for the malfunction is rooted in the contracts that Clalit Engineering, the engineering division of the health fund, signs with manufacturers. Unlike other hospitals, these contracts give Clalit more leeway in controlling and repairing medical devices.
On the other hand, Clalit officials clarify that all contracts are signed with the agreement and approval of the manufacturers. The probe is also looking into other possible factors that could have led to Har-Zvi's death, including a possible injury to one of Har-Zvi's arteries by the surgeon team.
Like most catheters, the one Har-Zvi was done using an angiographic catheter. "We usually enter it through the hand and inject contrast material into the arteries. With the angio device, we can see the arteries on the screen," explains Prof. Yehuda Adler, an expert cardiologist.
"This is how we can tell if the artery is blocked or not, and how blocked it is. That's the role of the angio device because if we don't see it, we don't know exactly where to open the artery, or if the patient needs bypass surgery. That's the goal of the device. Performing a catheter without angio is impossible and life-threatening."