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Hospitals and operating rooms must have surgical time-out policies and procedures in place to prevent this type of never-event error Contact Now

Surgeons admit under oath to operating on wrong kidney

Hospitals and operating rooms must have surgical time-out policies and procedures in place to prevent this type of never-event error

A few months ago, I wrote an article about a Tennessee surgeon who took a patient to surgery at Vanderbilt University Medical Center and operated on the wrong kidney. The medical malpractice lawsuit filed alleged that the woman would face dialysis for the rest of her life.

The plaintiffs’ attorney recently took the depositions of two physicians on the surgical team who admitted under oath that they mistakenly implanted a stent into the wrong kidney.

As an experienced Houston, Texas medical malpractice attorney, I’ve deposed countless defendant physicians. I’ve seen many of them testify under oath with a straight face that clear errors weren’t mistakes at all. When it comes to operating on the wrong surgical site, though, it’s hard to deny that something went wrong.

At their depositions, the surgeons blamed a malfunctioning electronic whiteboard for the error. One surgeon testified that he had reviewed the plan for the procedure beforehand, but then incorrectly remembered the details and didn’t double check his recollection. He said, “It was an inadvertent mistake,” and that he didn’t have an explanation for it.

The other surgeon said at her deposition that the snowball effect of errors began when she initially announced the wrong side of the patient’s body as the procedure site before surgery began. She explained that, under normal circumstances, the operating room physicians and nursing staff would have checked the surgical site information against an electronic whiteboard that displays patient information. Unfortunately, on the date of the surgery, the whiteboard wasn’t working.

While I appreciate the honesty of the surgeons in owning up to their mistakes, there are some lessons to be learned for all healthcare providers.

Wrong patient or wrong site surgical errors used to be so common that accrediting agencies like The Joint Commission implemented a universal protocol to prevent them. The universal protocol involves a surgical time-out before the operation begins, when the entire operating room team verifies the correct patient, correct surgical site, type of surgery, and other information.

The surgical time-out has been implemented virtually everywhere because human memory is fallible. This means that if an electronic whiteboard is malfunctioning, operating room staff need to find an alternate way to verify the correct patient, correct surgical site, and type of surgery before proceeding. That’s the only way to keep patients safe.

I have no doubt that this wrong-site surgery would have been avoided if the operating room providers had followed the universal protocol and surgical time-out requirements. Although these time-tested procedures have certainly reduced the number of these entirely avoidable surgical errors, they still happen surprisingly often.

Just in the last few years alone, I’ve represented Texas clients who were taken to the operating room for surgery by mistake (it was supposed to be on another patient) and who had to undergo extra procedures because a surgeon operated on the wrong site.

If you’re facing a surgery, I encourage you to be talkative and remind every nurse, surgeon, and physician that you encounter of your understanding of the surgery and the site where it’s to occur. If you are going to have a knee replacement, be sure to specify “right knee” or “left knee.” I spoke with a surgical expert once who told me that if he ever needed surgery himself, he would get a black sharpie and circle the correct side and put an X on the wrong side. That’s not a bad idea.

If you’ve been seriously injured because of a surgical error, either in the operating room or follow-up care, a top-rated, experienced Houston, Texas medical malpractice attorney can help you evaluate your potential case.

Robert Painter is an award-winning 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 all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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