Now, says the Associated Press (AP), the hospital has been fined $150,000 and mandated to take what the AP described as “the extraordinary step” of putting in video cameras in its operating rooms, citing Rhode Island health officials. The unprecedented move involves a nonsurgical team clinician observing hospital surgeries for one year, monitoring if surgeons are marking operation sites, and taking time outs to determine if the correct body part has been located for surgery, said the AP.

Rhode Island Hospital has 45 days to install the recording equipment in its operating rooms and every doctor will be taped during surgery at least twice a year, reported the AP. It will be at the hospital’s discretion to advice surgeons if they are being monitored.

Health officials and the State Department of Health were looking into how a surgeon at the hospital mistakenly operated on the wrong area of a patient’s hand. That alleged mistake represented the fifth such wrong-site surgery in two years at the hospital, a teaching hospital for Brown University’s Alpert Medical School. According to state health director, David Gifford, the $150,000 fine represents the second such fine in as many years, said the AP. The prior fine, for $50,000, was imposed following three wrong site neurosurgeries in 2007, added the AP, noting that, according to Gifford, these are the only two fines ever issued by his department.

While this was the third wrong-site surgery in one year, Rhode Island News reported that that surgery was the fourth wrong-site surgery in just six years, all taking place in the neurosurgery area.

The recent surgery, based on a letter previously cited by the AP, revealed that Hospital President Timothy Babineau said the error occurred late last week on a patient scheduled to undergo surgery on two fingers meant for a joint on one of the fingers, but operated on another finger. Babineau said, reported the AP, the surgery was then performed on the correct finger. The patient has since been released.

According to the AP’s recent report providing additional details on the scandal, the surgery was meant for two fingers; however the surgeon performed two operations on the same finger. The site of the planned surgery was to have been indicated, with the team ensuring—prior to making an incision—that they were operating on the correct patient, the correct procedure, and the correct body part, said the AP. The protocols are long established in the medical field and also include marking of the body part scheduled for the operation.

According to Gifford, the surgical team marked the wrist, not each of the two fingers; the surgeon did not mark the site, and the team did not take a “time-out” prior to the second surgery, said the AP. Apparently, when the error was discovered, the team confirmed with the family of the patient if they should conduct the correct surgery on the correct site, said the AP, but—astonishingly—even after the mistakes already made, the team still did not conduct the recommended timeout, a mistake Gifford described as “amazing.”

But, Kao, who admitted to “missing his target” when performing brachytherapy, claimed this type of error is not unusual and something for which he refused to be singled out, reported the Associated Press (AP). “Contrary to the allegations that I was a ’rogue’ physician, ... I always acted in the best interest of the patients in delivering this important treatment,” said Kao, quoted the AP. Kao, a radiation oncologist, was quoted when testifying at a Senate field hearing at the hospital, said the AP, noting that Kao worked at the VA center from 2002 to 2008.

KYW1060 reported that Kao testified that it is understood that radioactive seeds can move outside of the prostate to tissue and other organs, "The chance of seeds in the bladder, or outside the prostate, is a recognized risk of the procedure," said Kao. Senator Arlen Specter asked Kao at this point, "It's a recognized risk, but did you notify patients?" quoted KYW1060, to which Kao responded, "No sir.” Kao claimed such errors did not constitute a lower level of care that required reporting to the Nuclear Regulatory Commission (NRC) and other agencies, said the AP. “Brachytherapy was and still is an evolving field,” claimed Kao, quoted the AP.

The prostate is the size of a walnut and is located near the bladder and rectum, said the AP. Brachytherapy involves implantation of radioactive seeds to kill cancer cells, explained the AP previously, noting that most veterans allegedly received ‘”significantly less” dosing than what was prescribed, while others “received excessive radiation to nearby tissue and organs.” Brachytherapy is an option only used in patients diagnosed with “small, early-stage, non-aggressive prostate cancers,” said Philly.com.

According to an earlier AP report, the team performing the brachytherapy “botched” dosing on most cases, but continued to conduct treatment despite that “monitoring equipment was broken,” citing The New York Times. The AP reported that the NRC found incorrect dosing occurred because, generally, seeds landed outside of the prostate in tissue or nearby organs. Kao performed most procedures, said Philly.com, noting that Kao stopped seeing patients a year ago.

In one case, a patient testified to losing his job because he was forced on five months bed rest after Kao allegedly implanted radiation seeds into his rectum, not his prostate, said the AP. Although the VA said the problem likely came from hemorrhoids or constipation, an Ohio State University physician diagnosed the problem as radiation burn, surgically correcting the problem, the AP reported.

In another case, a patient underwent a seed removal from his bladder, alleged that three seeds were expelled in blood clots, and suffered radiation irritation to his rectum and bladder. The patient claims he never received the VA letter allegedly sent to all its brachytherapy patients. The cancer remains and the patient’s options are significantly limited and include surgery to remove the prostate, bladder, and colon, forcing use of urine and feces collection bags, said Philly.com.

The VA center’s brachytherapy program has been suspended, said the AP, noting that a review of 12 other VA hospitals in which brachytherapy is conducted revealed some problems, as well; none allegedly as severe or frequent as at the center in Philadelphia. According to the AP, Kao took a leave from the University of Pennsylvania last week.

• A glitch kept the warning from reaching the blood center’s computers.
• Blood center personnel had switched off a loud, high-pitched alarm that would have alerted them immediately.
• And they failed to check the instrument’s control screen, which turns bright yellow when bacteria are found.

• Donors of blood components, rather than whole blood, often receive back certain portions of their blood. In one case, a donor may have received damaged red blood cells that could have posed a health risk. The FDA found that center employees had not received formal training about such risks or instruction on how to minimize the health hazards.
• Several donors of blood components who experienced problems such as an allergic reaction, vomiting or loss of consciousness were told to donate only whole blood in the future. However, the blood center did not indicate this properly in the donors’ records. The center also failed to maintain about 244 reports of donor reactions from February through May 2005.

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.”

As we previously reported, in September of last year, two similar cases revealed that such “wrong-site surgery” and other horrific surgical errors occur all too frequently regardless of the country or the quality of the hospital or doctors involved.

In the first case (just then being reported by news sources in the UK), 52-year-old Marjorie Patterson had a routine mammogram which supposedly showed a suspicious shadow. After an MRI and biopsy, she was told by telephone that she had an aggressive type of breast cancer.

When 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 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.”

In September, 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.

Another similar error occurred 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 on 1 March 2000.

While one would hope these types of horrific mistakes were rare, the truth is they are not.
From 1985 to 1995 alone, the Physicians Insurers Association of America (PIAA) counted 225 claims for wrong-site surgery by its 110,000 doctors in the United States.

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.

This error, however, wasted two donor hearts and four donor lungs, caused a young girl to lose her one chance at a normal life, inflicted two weeks of unimaginable pain and suffering on the child including the need for a second transplant operation, and it killed her.

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 Mr. Heron’s case reveals, 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.

Before this week's startling  revelation that Peter Cura had died from kidney cancer that had gone undiagnosed some 37 times over 14 months, British medical authorities were already investigating at least three other highly embarrassing situations that had shaken the public's confidence in the nation's healthcare system.

In a period of less than three weeks between mid-January and February 10, the country was shaken by a series of potentially fatal errors by highly qualified doctors and medical personnel.     

This unbelievable sequence of events began when it was revealed that numerous mammograms had been mistakenly read as being cancer-free by the same radiologist working at North Manchester General Hospital in Crumpsall and Tafford General in the UK.

At least 28 woman were wrongly advised their scans were negative when, if fact, they actually revealed the presence of breast cancer in its early and more treatable stages.

At least 17 of those women are now suffering from advanced stages of the disease and are at serious risk of dying as a result of the misdiagnoses. The investigation into the matter only promises to uncover more examples of malpractice by this radiologist.

Less than a week later, came another startling report of misread tests at the same medical trust. This time, hospital officials admitted more than 1,000 patients may have been wrongly diagnosed with heart problems by a cardiac technician at Fairfield General Hospital in Bury, Greater Manchester, when, in truth, the readings were actually normal.

Some 1,053 patients have been notified by the hospital that their records must be re-examined due to errors that were found in evaluating echocardiogram tests.

Dr. Ruth Jameson, acting medical director of Pennine Acute Trust, which runs the hospital, said: "This technician, who was supplied by an agency, is no longer doing any work for the Trust."

According to Dr. Jameson, not all patients who had undergone ultrasound heart scans were affected. Only those who had seen this specific unnamed technician between May 23 and December 7 are at risk of having inaccurate echocardiograms.

Dr Jameson said: "We are hopeful that the particular echocardiograms will not have had a major adverse effect on patients but the only way we can assure our patients that they are having the appropriate care is to carry out this review."

The review is expected to take several weeks and hospital officials have not yet determined whether any patients were given the wrong medication as a result of the cardiac technician's errors.

Then, possibly the most horrendous error in that appalling trilogy came to light with the disclosure that after undergoing months of treatment for a brain tumor, which included 17 sessions of radiation therapy, a 15-year-old girl was given the "all clear" by her oncologists only be told shortly thereafter that she now faces, brain damage, paralysis, and eventual death, not from her cancer, but from the treatment she received.

As it turned out, at each of her 17 radiotherapy sessions Lisa Norris received a massive overdose of radiation.

This horrible mistake (17 horrible mistakes to be more accurate) has left Lisa in constant pain, and unable to sleep. Her red and blistered body is burned to the point where she must take frequent cold showers simply to cool down.

She was literally cooked from the inside with doses of radiation so excessive that she has been told that there is the distinct likelihood she has suffered irreparable brain damage that may leave her paralyzed and eventually kill her in as little as 10 to 15 years.

Ironically, she has been sentenced to a protracted and hideous death by her doctors and not by the cancer from which they were trying to save her.

The hospital, Beatson Oncology Centre in Glasgow admitted that "human error" had led to Lisa being given overdoses at each of her 17 scheduled radiotherapy sessions. Beatson is the second largest cancer centre in the UK and has a global reputation.

According to The Daily Mail, which has been following this story from the beginning:

Professor Alan Rodger, the center's medical director, said: "My colleagues and I deeply regret the error that has led to Lisa Norris being given an overdose of radiation during her course of treatment. The staff involved with his isolated incident is extremely distraught. Initial meetings have taken place with Lisa and her family and we will do everything in our power to support them in the challenges ahead."

"I've been told I could be brain damaged, could be paralyzed and in ten to 15 years I might not be here, I could die," Lisa said.

"I could have a scar on my head or brain which can lead to strokes, heart attacks and whatever else.

"I don't know what is going to happen to me, it could happen in the next six months to a year. We just don't know what is going to happen.

"I've got burns on the back of my neck and ears and they're starting to blister.

"I can't sleep because I can't lie on my back. I can't really do much, my mum has to help me put my clothes on."

Lisa's distraught parents are not inclined to simply accept the center's apology. They want the five staff members responsible for the errors fired.

Lisa also stated (as reported by The Daily Mail):

"I'm really angry with them, they shouldn't be able to get away with it," said Lisa, from Girvan, Ayrshire.

"By rights, they should be put out of their jobs and not allowed to work in the NHS ever again because it could happen to somebody else."

Prior to the bungled radiation therapy, Lisa had undergone chemotherapy that had sickened her and made her hair fall out. Following the radiotherapy, however, Lisa and her parents were told that the tumor was gone.

Shortly thereafter, however, Kenneth and Elizabeth Norris were told that "two consultants were coming to see them." (Daily Mail). "We knew something was wrong," said Mrs. Norris, 49. "You never hear of consultants visiting your house, so alarm bells were ringing."

Her husband, a 50-year-old joiner, said: "It just knocked us for six. We've not been able to sleep a night since. If they can do this to Lisa, they can do this to anyone."

A full-scale inquiry into that tragic medical blunder was launched.  "The inquiry is being conducted by the Department of Health and the radiation protection division of the UK Health Protection Agency."

"It has not yet emerged how the wrong dose of radiation was administered 17 times."

"But it is thought that the wrong level was given on Lisa's first session and then repeated because it was written in the notes with no one spotting that it was too high." (Daily Mail)

Lisa, who is now being home-schooled, will be having an MRI brain scan in three weeks to start the process of assessing her condition.

Martin Ledwick, of Cancer Research UK, said: "Obviously as a health professional working with cancer patients for a number of years I was very shocked and surprised that this happened as I'm aware of all the checks that are in place to avoid this sort of mistake being made."

By comparison, however, the latest case may very be the worst of all. Could it be possible that doctors had actually failed to diagnose kidney cancer 37 times in 14 months? Apparently, the answer is yes.

Peter Cura, 31, a carpenter from Rainham (UK), was suffering from severe, chronic back pain and was repeatedly examined by hospital staff at Medway Maritime Hospital in Gillingham, Kent.

Classic symptoms of kidney cancer along with numerous scans and six surgeries repeatedly produced a diagnosis of kidney stones.

It was only Mr. Cura's persistence that led to him having a CT scan that showed his left kidney had stopped functioning and required removal.

When that surgery was performed, a three inch malignant tumor was finally discovered. Additional tests showed the cancer had spread throughout Mr. Cura's body.

Nearly 18 months after his initial visit to the hospital, Cura was told his cancer was incurable. He passed away last week.

Just two weeks prior to his tragic death, the father of  two (Lewis, 6, and Abbie, 3) had stated:

"I mainly feel anger with the doctor I was seeing at the time. It crossed my mind that it might be cancer. But when I asked the doctor he said, "Definitely not".

"When the kidney was taken out, it was sent for tests and they found a tumour, 8cm across, but even then we were told there was nothing to worry about.

"I try not to think about it (dying) too much but I am angry about the way the doctor was so blase about it."

Julia, his wife, who may sue the trust that runs the hospital, added: "We want the hospital to admit what they have done and to do something about it so that others don't have to go through this."

The family is being represented by Sarah Harman who was quoted as stating: "It is tragic that such a young man with a family should have lost his life in a situation that was avoidable.

"The care provided by Medway Maritime Hospital was far below what he had a right to expect. One mistake can be excused, but in Peter's case there were a series of lost opportunities when his life could have been saved."

Mr. Cura's ordeal began in April 2002 when he went to the emergency department of Medway Maritime complaining of excruciating back pain. That unbearable pain continued despite undergoing a series of scans and X-rays, and five operations to remove kidney stones.

Although Cura visited the hospital 37 times, often in the emergency and the outpatient departments, the correct diagnosis was never made. Not once at any of these visits was kidney cancer raised as a possible cause.  

It was not until December 2003 that he was told the cancer was almost definitely incurable. That diagnosis/prognosis came only after Cura, himself, had insisted on the CT scan that led to his kidney being removed in July 2003.

Although a spokesman for the trust that owns Medway confirmed the delay in diagnosing kidney cancer, he denied that the belated diagnosis had allowed the cancer to spread. The hospital's position is that Cura's condition would have been the same even if they had discovered the cancer from the beginning.

Nonetheless, the spokesman claimed that: "Measures have been put in place to address the issues raised in the claim in the hope of preventing similar such cases."

When we spoke with an attorney familiar with medical malpractice litigation, he told us that doctors and hospitals faced with indefensible factual situations, such as this one, often take the position that their malpractice did not affect the outcome.

As the attorney stated: "What better position could a defendant who committed clear malpractice take than to claim that the patient was, for all intents and purposes, already dead as a result of his or her disease before the defendant ever became involved? In that way the defendant can argue that nothing could have been done to save the patient even had the proper diagnosis been made immediately."

Even such a maneuver, however, does little to address the larger issue which is; what is allowing so many extreme cases of medical malpractice to occur in the UK at the present time?   

(Sources: Daily Mail; newsinferno.com Archives)

Despite strong warnings from one of the surgical nurses and an assurance from the supplier (Medtronic Sofamor Danek) that new titanium rods could be delivered within 90 minutes, the surgeon, Robert Ricketson, decided that he would use the shaft of a stainless steel medical screwdriver instead.

Although Ricketson's decision that it would be a good idea to substitute part of a stainless steel screwdriver for a titanium implant would, by itself, probably have justified the verdict, the remainder of the facts make the case even more astonishing.

As it turns out, the hospital, Hilo Medical Center, issued credentials to Ricketson despite the fact that he had been suspended from practicing medicine in Texas and Oklahoma for alleged drug use.

Ricketson had no malpractice insurance and acted as his own attorney at trial. He will probably never be able to pay the judgment against him.

The implanted screwdriver shaft lasted only a week before breaking in Mr. Iturralde's back. A second (and then a third) operation was required to correct the problem created by Ricketson's creative carpentry work.

Iturralde, who was 73 and in poor health, never recovered from the complications of the botched surgery. His condition deteriorated and he died in 2003 at 75.

The jury found Ricketson 65% liable and Hilo Medical Center 35% responsible. The verdict of $5.6 million was made up of $307,000 for "special damages' (medical bills), $1.87 million general damages (conscious pain and suffering), and $3.4 million in punitive damages (100% against Ricketson since Hawaiian law precludes punitive damages against hospitals).

Although Medtronic was also sued, the jury did not find it liable. The company claimed it had sent the original rods (the hospital denied receiving them). Medtronic also argued the surgical team should have checked if the  rods were in the operating room before the surgery was started. There was also the fact that it offered to rush replacements to the hospital during the surgery.

• Against a government agency that operates hospitals or provides specified medical care.
• Against a hospital for administering improper or overdoses of medication, negligent nursing care, inadequate sanitation, infection, or equipment failure.
• Against a physician, who in the general practice of medicine, deviate from the general accepted standards of practice in the community.
• Against a medical specialist who deviates from a nationally accepted standard of practice for specialists in that field of medicine.

• The physician delayed diagnosis of a medical condition, or failed to diagnosis the patients medical condition altogether;
• The physician properly made the correct diagnosis, and then failed to properly treat the medical condition properly;
• The physician failed to perform a surgical procedure properly; or
• The physician fails to obtain the informed consent of the patient before performing a procedure or operation.