Two years ago in February, a 59-year-old federal inmate went under the knife at St. Jude Medical Center in Fullerton to have his diseased left kidney removed.

He emerged from the procedure with his tumor-laden kidney still intact. The surgeon, Dr. Charles Coonan Streit, a urologist who has had his license for 41 years, mistakenly had taken out his healthy right kidney.

Last week, the California Medical Board disciplined Streit for the error, placing him on probation for three years.

According to the medical board, on the day of the operation Streit relied on memory to decide which kidney to remove because he didn’t have access to the patient’s complete medical records. And the paperwork Streit did have was incorrect: It showed the patient was admitted to St. Jude with a cancerous right kidney, according to the California Department of Public Health.

There were CT scans showing the cancer on the left kidney, but the images were left behind in the office of one of the surgical team’s doctors that day, according to the department of public health. It fined St. Jude $100,000 last year for the mistake.

“The images were performed at another facility and were not available,” DruAnn Copping, a St. Jude spokeswoman, said in a statement. Copping said the hospital now mandates such images be submitted before a procedure is scheduled.

The medical board called the error “an extreme departure from the standard of care.”

It concluded the error could have been avoided had Streit followed standard operating protocol: Defer to labeled radiology and diagnostic tests, images, scans and pathology reports. He also could have done a renal ultrasound to confirm the location of the tumor but did not.

As the surgeon, it was Streit’s “sole obligation” to review the diagnostic images, the medical board said.

The attorney representing Streit did not reply to a message seeking comment.

A 2006 study found that wrong-site surgeries are exceedingly rare, especially in the larger context of medical errors, a category that also includes injuries from falls, bedsores and infections. The authors of that study, which was published in the Journal of the American Medical Association, suggested that wrong-site surgeries might happen only once every five to 10 years at large hospitals.

Surgeons are more likely to leave objects, such as sponges and instruments, behind in the body after stitching up an incision, the study found.

In the past seven years, the Department of Public Health has fined two other Orange County hospitals, Mission Hospital Regional Medical Center in Mission Viejo and St. Joseph Hospital of Orange, for wrong-site surgeries. In that same time period, the state levied nine fines against local hospitals for retained objects.

Still, as wrong-site surgeries are preventable and complications, including possibly death, are so serious, they have drawn the attention of regulators and consumer rights advocates.

In 2003, the major accrediting agency for hospitals, the Joint Commission, hosted a summit on the topic. The UC San Diego School of Medicine offers a wrong-site surgery course.

Streit is required to enroll in that class within 60 days as a condition of his probation. He is also barred from supervising physician assistants.

The nurses and an anesthesiologist who assisted Streit in the kidney surgery told state inspectors that they repeatedly asked the patient which kidney was diseased, and he told them the wrong side. According to the state’s report, a nurse said “for some reason” she thought “the surgery was (supposed to be) on the left side but double-checked the records and it was the right side.”

“It was our failure to follow our protocol regarding displaying the patient’s diagnostic images that ultimately resulted in this error,” hospital spokeswoman Copping said.

The patient was serving time at Terminal Island, a low-security federal prison in San Pedro. He had undergone two CT scans at Long Beach Memorial Medical Center that showed a mass on his left kidney, which a radiologist suspected was renal cell carcinoma.

The mistake put his “future renal function in jeopardy” and forced him to have a second surgery, according to the medical board.

Streit remains on staff at St. Jude, Copping said.

Contact the writer: jchandler@ocregister.com Twitter: @jennakchandler