Ouma Oluga, chief executive officer of the Kenya Medical Practitioners, Pharmacists and Dentists’ Union, said in a televised interview the mix-up on Sunday at Kenyatta National Hospital laid bare the dangers to patients of an“overwhelmed” system and staff.

Kenyan media reported that a neurosurgery registrar, anesthetist and two nurses had been suspended by the hospital.

The Daily Nation reported that doctors did not realize they had opened the skull of the wrong patient until two hours into the procedure meant to remove a blood clot. Both the person operated on and the blood clot patient are in good condition, it said.

The hospital’s spokesman did not answer requests for comment.

“These are quality system issues that should not be leveled at staff,” Oluga said, adding punishing doctors and nurses would not address problems in the patient tracking system.

A shortage of medical staff and inadequate theater space made errors more likely, Oluga said.

“Doctors are overwhelmed. You find one doctor could be doing 10 to 19 operations [in a day],” he said.

Government-employed doctors say they are poorly paid and work without adequate equipment. Last year the government granted them a pay rise promised in 2013 after a three-month strike.