When Surgeons Operate on the Wrong Site

When a person goes into the hospital for a surgical procedure, the last question to cross their mind may be: “what happens if the doctor does the wrong surgery?” But, as it turns out, sometimes doctors perform the wrong procedure altogether, and at other times they may do a surgery on the wrong site of their patient’s body. A new study finds that if doctors referred to operating room checklists, the likelihood of severe medical mistakes such as these may very well decrease.

Sometimes, the serious, potentially deadly mistake of wrong site surgery is caught before it is too late. This was the case for a male patient who went into a California hospital to have an orchiectomy done. An orchiectomy is a surgical procedure to remove one or both testicles. This patient was having a left orchiectomy. Unfortunately, before the surgeon recognized the mistake, a surgical incision was made into the patient’s right groin. Luckily, the error was noticed before surgery continued, and in the end the patient had the left testicle removed.

There are times when a wrong site surgery is not caught in time. Another, less fortunate patient entered a hospital for a left nephrectomy, a procedure that involves the removal of the full or partial kidney. The surgeon, however, removed the right kidney. Although this is astounding in and of itself, even more frightening is that this mistake was not caught until a subsequent pathology report was taken, illustrating the surgical results. The patient still had a cancerous left kidney intact, and now had lost their right, perfectly healthy one.

In these two instances, the hospitals at which the grave mistakes occurred were fined various amounts of money: $75,000 and $100,000 respectively. But no changes were made to hospital systems or protocols, because it appeared as though all rules and standards had been followed; operating room checklists were in place and it was expected that the appropriate precautions had been taken. The main reason for the mistakes was quite simply human error. Other examples of wrong site surgeries only further prove this startling reality.

A hospital in Florida was threatened with the loss of its Medicaid and Medicare provider agreements as a result of a possible cover-up and failure to report as a result of wrong site surgery. A female patient was admitted for a vascular surgical procedure on one of her legs. Once surgery had been initiated the anesthesiologist on staff realized that the surgeon was performing on the incorrect leg and immediately reported the error. The surgeon, however, continued with the surgery and then conducted the procedure on the correct leg afterwards. When the patient awoke from the double procedure, the surgeon had her sign a consent form for the leg he had mistakenly performed surgery on and reportedly told her that she had needed that surgery in addition.

It took the hospital two weeks to report the surgeon’s mistake, which should have instead been reported immediately. As a follow-up to the report, a state inspection on the hospital was conducted. The inspection uncovered an array of issues, and many of them seem to point to a larger issue that is occurring nationwide: that operating room checklists may be present, but are not being referred to and working in the ways they need to be.

Researchers have found that at some hospitals, operating room checklists are commonly used but more than half the time contain incorrect patient information. Furthermore, one-fifth of the time the operating room checklists being referred to had incomplete information. The main purpose behind the checklist, which was compiled by the World Health Organization (WHO), is to improve the overall safety of surgery as well as to reduce the number of patient complication and deaths.

The surgical safety checklist has three separate columns, divided into questions to ask before anesthesia, before a skin incision is made and finally, before a patient exits the operating room after having surgery. If we think back to the example of the patient who suffered the mistake of having the wrong kidney removed during surgery, had the operating room checklist been correctly completed, used, and the question “Is the site marked?” considered, the wrong site error may very well have not occurred.

It is the responsibility of hospital administrations to require for the full implementation and actual use of the operating room checklist. Surgeons, too, with the knowledge that wrong site surgeries do occur and that human errors are made, should refer to these checklists for important, patient information and comprehensive health questions.  With the goal of reducing patient complications and deaths, all medical professionals should be onboard with compliance to the use of operating room checklists.  Doing so, could potentially avoid serious medical mistakes.

Philadelphia Medical Malpractice Lawyers at Galfand Berger, LLP Advocate for Victims of Surgical Errors

The Philadelphia Medical Malpractice lawyers at Galfand Berger have successfully represented clients who have been injured due to medical negligence, malpractice and misdiagnoses. If you or any of your loved ones have experienced such a situation, an attorney at Galfand Berger, LLP can help. With offices located in Philadelphia, Reading and Bethlehem, we serve clients throughout Pennsylvania and New Jersey. To schedule a consultation, call us at 800-222-8792 or complete our online contact form.