I am currently working on a case on behalf of a patient who was taken to the operating room by mistake. It turns out that there were two patients in this northwest Houston area hospital with the same last name and there was a mix-up. While it is surprising that the staff got the wrong patient in the first place, it is shocking that the surgeon and operating room staff proceeded to perform the surgery on the wrong patient who did not need it the first place.
After the fact, the surgeon apparently recognized his mistake and asked and nurse to place an order in the medical record that would make it look like the surgery consultation had been ordered by another doctor, the attending physician. When the attending physician saw this, he had no part of it and made it clear in a medical record notation.
My client is elderly and hard of hearing and was helpless to stop the surgeon and nurses. After the unneeded surgery, she required a colostomy bag for several extra months and went through a lot of pain, suffering, and mental anguish.
I thought that this was such an outrageous situation that I contacted the hospital and attorneys for the surgeon. The hospital was quick to admit that there was a problem, but the surgeon’s attorney took the position that it was no big deal, adding a commenting attributed to the surgeon that the patient would have probably needed a surgery in the future anyway.
Needless to say, I am preparing the case to file as a new medical malpractice lawsuit in Harris County. I have already retained a prominent local board-certified surgeon, who is preparing an expert report that will detail what went wrong.
As a Houston, Texas medical malpractice lawyer, I know that mistakes in surgery is ongoing. In fact, the major accrediting agency for hospitals, The Joint Commission, announced that one of its 2018 National Patient Safety Goals focuses on preventing mistakes in surgeries, particularly through three new standards.
When conducting on-site accreditation surveys, The Joint Commission checks to make sure that that the hospital has these three new standards in place.
The first standard requires that hospitals have policies and procedures in place that make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. I actually had a case several years ago where the other side presented a surgeon at trial who admitted that he had amputated the wrong leg on a patient.
The second standard requires operating room staff to mark the correct place on the patient’s body where the surgery is to be done. In other words, the surgeon or operating room staff will get a marker and draw around the operative site. I have heard of cautious patients doing this on their own, either marking the site of the anticipated surgery or writing something like “wrong knee” on the other side.
Finally, the third standard requires the surgical team to pause before the surgery to make sure the mistake is not being made. This has long been called the surgical time-out. The surgical time-out should occur when the patient, surgeon, anesthesia provider, and other key players are in the operating room. It is a short conversation where the patient’s identity, surgical location, and other key information or verified.
As a former hospital administrator, I know the policies and procedures are not enough. Whether at a regular acute care hospital or at an outpatient surgery center, leadership must maintain a robust training program to ensure that operating room staff are aware of policies, procedures, and standards. In addition, annual competency assessments and evaluations must be in place to hold healthcare providers accountable for providing good care.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2017, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.