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Wrong Site Surgery: Zero-Tolerance Is the Only Acceptable Standard

Aug 1, 2006

There are many situations that can be interpreted quite differently depending on the perspective of the person making the observation. Clearly, a half-empty glass is also half-full and “one man’s meat is another man’s poison.” Likewise, if you are being attacked by a shark and it swims away after you punch it in the snout, the procedure was 100% successful. If the shark shakes off the blow and eats you, the procedure was 0% successful. A person compiling statistics with respect to methods that might ward off a shark attack, however, could list “hitting the shark in the snout” as 50% successful if half of those employing the strategy avoid becoming a meal. Unfortunately, the remaining victims, who still end up as a tasty morsel, will find little consolation in the fact that the procedure may have worked for someone else.

Recently, on the very same day, two respected publications featured headlines that closely paralleled the above examples of “beauty is in the eye of the beholder” scenarios. While the headline on WebMD Medical News read, ‘Wrong Site’ Surgery Is Rare, the one on USA Today claimed, ‘Wrong site’ surgeries on the rise.

If all that was being discussed was the probability of finding one broken egg when you opened a sealed Styrofoam container, the two views of the problem could be dismissed as nothing more than a difference in perspective. When you considerer, however, that what is being discussed are errors that include removing the wrong kidney, breast, or leg, or operating on the wrong side of the brain, any positive “spin” placed on the infrequency of the occurrence is inexcusable.

 The WebMD article discusses a new study that places the risk at one in 113,000 and characterizes that figure as “small” and “extremely rare.” It also acknowledges that, since “No protocol will prevent all cases,” it “will ultimately remain the surgeon’s responsibility to ensure the correct site of operation in every case.”  The study authors place emphasis on the fact that wrong-site surgery is “shocking to the public.”

Clearly, the public has a right to be shocked at such errors regardless of how infrequently they occur since each one of them is a medical mistake that should never have happened.

The USA Today article reports that the frequency of wrong-site surgery is increasing. The problem is “getting worse” and, because of underreporting, one expert states that: “I can assure you that this is just the tip of the iceberg.”

While relying on the same study, the people interviewed by USA Today (as opposed to WebMD) view the problem as one that must be reduced to “zero” since, “It is such a catastrophe when this happens.”

The study documents various cases of wrong-site surgery that range from minor to catastrophic. It even discusses one case in which surgery was performed on the wrong person.  

One expert sees part of the problem as surgeons “who believe they would never make such a stupid mistake” ignoring “safety protocols.” Disputes, between surgeons and operating room nurses, over safety checks is another source of potential mistakes. Speed, as opposed to safety, can also be a problem when it is the standard by which a hospital gauges efficiency.

Wrong-site surgery is, all too frequently, a trip down a one-way street that cannot be reversed. Many times, it is a fatal mistake or one that leaves the patient significantly worse off than he or she was before the surgery. It can leave the victim with a lifetime of suffering. To appreciate why wrong-site surgery is so “shocking to the public” and why even one in 112,994 cases is one too many, we have compiled the following research with respect to particular cases that demonstrate the potentially catastrophic nature of this type of medical mistake or mistakes caused by errors committed with respect to diagnostic tests done prior to surgery.

Late last year, reports of operations that took place on different sides of the Atlantic shared a common result; the patients were catastrophically injured by inexcusable surgical errors.

In the first case, 52-year-old Marjory Patterson had a routine mammogram which supposedly showed a suspicious shadow. She was referred to a local hospital, NHS Highland’s Raigmore Hospital in Inverness (UK), where an MRI and biopsy were performed.

She was told by telephone that she had an aggressive type of breast cancer. Later, doctors advised her that a mastectomy was needed to save her life. She agreed, and the surgery was performed.

Three weeks later, doctors admitted the biopsy they had examined belonged to another patient and that Mrs. Patterson never had cancer. The hospital referred to this unforgivable mistake only as a “tragic case where a mistake was made.”

The Daily Mail reported Mrs. Patterson as stating: “No one can understand what it’s like to be told you have a disease that could kill you. Then to be told it was a mistake is just disgusting. They can’t bring my breast back – I am disfigured for life.”

As bad as this case is, the error did not affect Mrs. Patterson’s actual lifespan. In the next case (and an older third case) the same cannot be said.  

In September 2005, the New York State Health Department announced it was launching an investigation into what happened at Phelps Memorial Hospital Center in Sleepy Hollow, New York, where surgeons removed a man’s perfectly healthy kidney instead of his cancerous one.

The patient was left with only one diseased kidney which must also be removed to prevent the spread of the cancer. As a result, the patient will need constant dialysis and a kidney transplant in order to survive.

This horrible case is very similar to one in the UK in January 2000 when two surgeons removed a man’s healthy kidney instead of his diseased one. One of the doctors told a disciplinary panel that
he had collected x-rays but had read them the “wrong way round.” He realized something had gone wrong when, two hours after the surgery, the anesthetist told him that the man had not produced any urine

The surgeon then tried to "rescue" the good kidney so that it could be replanted but it had already been put in sterilizing agent and that was not possible. An attempt to get the man’s diseased remaining kidney to work was also doomed. Five weeks after the botched surgery the 69-year-old man died.

In January of this year, officials at Children’s Hospital of Orange County (“CHOC”) claimed that an “error” was the first of its kind in the hospital’s 42-year history. As a result, the hospital announced it will implement new operating room rules designed to prevent any such errors in the future.

After an investigation, the California Department of Health Services found that on January 13, CHOC surgeons opened the wrong side of a child's skull during an operation to remove a brain tumor. The agency's report noted that the doctors involved failed to observe the “time out” before the surgery and failed to mark the operation site on the child’s head.

 The error was discovered when no tumor was found under the portion of skull initially removed. At that point, the doctors replaced the section of skull removed by mistake and proceeded to the correct operative site where the tumor was located and removed. Reportedly, the child suffered no complications as a result of the error (beyond those immediately attributable to the wrong-site surgery itself, of course).

The Department of Health Services also found that the doctors failed to document the wrong-site surgery in the child’s hospital chart. The hospital did, however, notify the state thereby prompting the investigation. The agency concluded that the mistake may have been the result of a doctor moving the operating table in order to make room for an assistant surgeon. This may have caused the operating team to become disoriented.  Although the child was under the care of CHOC doctors, the incident occurred at nearby St. Joseph Hospital, where CHOC contracts for additional operating space.
The hospital was given until April 17 to submit a "plan of correction" to the Department of Health Services detailing the changes it intends to make to prevent similar occurrences. CHOC announced that in the future, cutting instruments will be removed from the immediate operating area until surgeons complete the required "time out" in order to identify the correct operative site and that the surgical team will make certain the proper area to be operated on is clearly marked.

Some other notable cases that came about because of simple mistakes include one in 1995, at Tampa's University Community Hospital, where a surgeon amputated the wrong leg of 51- year-old Willie King.

The 59-year-old mother of a prominent Indian film star was brought to Sloan-Kettering Cancer Center in New York to have a malignant brain tumor removed. The neurosurgeon operated on the wrong side of her brain. The woman now suffers from severely impaired vision and no awareness of her left side. (Washington Post, 7/25/95).

A surgeon at Butterworth Hospital in Grand Rapids, Michigan, cut off the wrong breast of a 69-year-old cancer patient during a mastectomy. (USA Today, 3/27/95).

A surgeon in Boston removed the wrong kidney from a patient after failing to check x- rays that would have revealed this tragic error. (Boston Globe, 6/1/96).

In a particularly tragic case, Jesica Santillan, a 17 year-old girl from Mexico who was smuggled into the United States to receive treatment for a life-threatening heart condition, waited three years for a donor heart and lungs to be found.

When the heart and lung transplant, which was supposed to save her life, was finally performed, her condition only worsened. It was then discovered that the heart and lungs she received did not match her blood type. Jesica required a second transplant operation two weeks later but the damage to her brain and other organs was irreparable. Jesica experienced brain damage and kidney failure, was ultimately declared brain dead, and removed from a respirator.

After this tragedy, Duke University Hospital, which admitted it had made an inexcusable medical mistake in cross-checking blood types, initiated a three-person verification system to ensure that the blood type of the donor and recipient match.

 A 67-year-old man named Hurshell Ralls went into surgery for bladder cancer and, while under anesthesia, the surgeon removed his penis and testicles because he concluded that the cancer had spread to the penis. No one had ever discussed the possibility of such radical additional surgery with Mr. Ralls who was shocked to learn what had happened to him at a time when he was unable to make a conscious decision about the removal of his penis and testicles. Later, after examining a tissue sample, another doctor concluded that Ralls never had cancer of the penis.

In May of 2002, Linda McDougal was diagnosed with breast cancer and underwent a double mastectomy at the United Hospital of St. Paul Minnesota. After the surgery, McDougal was told that she had never had cancer. Apparently, her slides had been mixed up with those of another patient.

As the CHOC case and many of the others reveal, these tragic, inexcusable errors continue to occur at even the most prestigious hospitals. Simple mistakes and failures to obtain or check critical information repeatedly act to undo even the best safety procedures that are supposed to guard against catastrophic surgical errors.

Serious surgical mistakes often begin as simple errors that go undetected. Reading the wrong patient’s hospital chart or test results, failing to look at an X-ray or looking at one backwards, improperly filled out forms, or marking the wrong surgical site have all resulted in catastrophic mistakes in the operating room. Sometimes the mistake is discovered during surgery; however, in most cases the error is only revealed afterwards. In either case, it is usually too late to undo the damage.

 Apparently, the facts leading up to the removal of the wrong (healthy) kidney of a 63-year-old cancer patient followed this familiar, but tragic, pattern. The man, John Heron, gave an exclusive interview to that revealed the type of “comedy of errors” that often produces the occurrence of what is known as “wrong-site surgery.”

In the interview, Mr. Heron stated that before the surgery he clearly told doctors that the pain he was experiencing was on his left side. His right side had already been marked, however, and he was told not to worry. At the time, his doctors had not reviewed X-rays that clearly showed the cancerous tumor was on Heron’s left kidney.   

Following the surgery, Heron was even told that he was “a lucky man.” The next day, however, he was told the terrible news after the pathology lab found the kidney that had been removed to be completely healthy.           As the result of this “disastrous” mistake, Heron faces years of dialysis and an uncertain future. He must await a donor kidney, which could take two or more years and he must undergo additional surgery to remove the tumor and cancerous portion of his left kidney. Even under the best of circumstances – should a family member prove to be a compatible donor – the surgery would have to wait for at least two years because of the cancer.

Mr. Heron was admitted to Ayr Hospital earlier this month after doctors discovered a tumor on one of his kidneys. What followed was characterized by his family as a "disastrous" mistake and “disastrous professional errors that should never have happened.” The family is “devastated” and wants “to ensure that everything is now focused upon providing the best medical experience and care for my father."

The executive medical director of NHS Ayrshire and Arran apologized to the family on behalf of the hospital, saying: "It is with deep regret I can confirm a patient had a healthy kidney removed. The board at NHS is now planning future medical care for Mr. Heron. "Our thoughts are with the patient and family, to whom we apologize for this tragic error."

Although treatment for a gallstone problem had revealed a small cancerous tumor on the left kidney, and surgery had been scheduled for March 8, the GP’s letter and CT scan report identified the right kidney as the one with the tumor. Instead of waiting to examine the X-rays, the surgeon, Riza Murat Gurun, decided to proceed with the operation since Heron had been “prepped.”

Clearly, these extremely tragic, inexcusable errors continue to occur at even the most prestigious hospitals and regardless of sophisticated safety procedures in place to guard against them. Human error remains a serious problem especially when surgeons scoff at protocols or refuse to cooperate with operating room nurses who attempt to follow the rules. Encouraging speed over safety in order to do more operations is also a practice that must be stopped at major hospitals.

In the end, however, the most important thing to keep in mind is that there is no tolerable level of risk when it comes to wrong-site surgery or surgical errors caused by negligence in pre-surgery diagnostic testing. There should be a no-tolerance rule with respect to these medical mistakes that take or destroy lives for no acceptable reason.

If you or a loved one has been the victim of wrong-site surgery, a surgical error, or some other type of medical malpractice, do not hesitate to contact Parker & Waichman at for a free consultation. Even if you only suspect that an error has been made, you should investigate the matter further by discussing it with one of our attorneys as soon as possible to avoid losing your right to seek compensation because of the running of the applicable statute of limitations.    

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