It seems almost impossible to consider that a licensed doctor could operate on the wrong part of your body and not notice until it was too late. Victims of surgical errors are often shocked to find out just how common a wrong surgical body part surgery can be. There is no excuse for such a terrible medical error but doctors and hospitals may still try and limit the victim’s recovery options.
After a medical malpractice injury caused by a surgeon’s error, the injury victim may be left requiring additional medical care to operate on the correct body part. After recovery, the victim may be disabled, disfigured, or suffering chronic pain. The patient deserves compensation for their losses, which can include loss of income, medical bills, and loss of enjoyment in life. If you need to file a medical malpractice claim, talk to an experienced medical malpractice law firm about your options.
Surgery on the Wrong Part of the Body
According to a study published in the Archives of Surgery, there are an estimated 1,300 to 2,700 wrong site surgeries each year in the United States. However, they may be more common than health care providers and patients understand because hospitals are not required to report all these types of wrong site surgeries. The term “wrong-site surgery” sometimes includes other surgical mistake errors, including:
- Wrong side surgery
- Wrong procedure surgery
- Wrong patient surgery
Wrong Site Surgery
A wrong site surgery means the surgeon operates on the wrong area of the body. This could be the wrong side (left vs. right), wrong limb (arm vs. leg), or even the wrong tooth in an oral surgery. Surgery on the wrong site can have multiple serious consequences. First, the area that required treatment is left untreated and could still pose a risk to the patient. Second, the healthy body part is unnecessarily treated, amputated, or disfigured.
Wrong Side Surgery
Wrong side surgeries are common wrong site accidents because the human body is mirrored in many ways on the right and left. In bilateral symmetry, there is an equal arrangement of body parts on a vertical line from head to toe. Most people are born with equal limbs and dimensions on their left and right body, with exceptions for several internal organs, like the heart, liver, or stomach. Mixing up right versus left could result in severe wrong side surgery damage.
Wrong Procedure Surgery
Wrong procedure surgery can be more complicated. With a wrong procedure medical error, there is generally some mix-up with the paperwork, rushing to complete the procedure, or change in scheduling for patients. This could mean patients coming into the hospital for removal of their gallbladder could end up losing their liver. The damage for wrong procedure accidents can be physically and mentally detrimental for patients.
Wrong Patient Surgery
In a wrong-patient surgery, again, there may be some confusion in scheduling and record-keeping that ends up treating a patient with the surgical procedure intended for someone else. Incredibly, wrong patient surgeries can occur and remove healthy body parts and organs just because the doctor mixed up the patients.
Never Events and Medical Errors
Wrong site surgeries are known as “never events.” Also referred to as serious reportable events (SREs), these are medical errors or medical accidents that should never happen. Serious medical errors that often occur in hospitals or clinical settings are supposed to be preventable. When these accidents do occur, they are generally attributed to a mistake or lack of following the proper procedures. According to the National Quality Forum (NQF), surgical or invasive procedure never events include:
- Surgery or other invasive procedure performed on the wrong site
- Surgery or other invasive procedure performed on the wrong patient
- Wrong surgical or other invasive procedure performed on a patient
These never events can happen in a variety of health care settings, including hospitals, outpatient surgery centers, ambulatory practice settings, and skilled nursing facilities.
Considering they are called “never events,” they occur more often than you might expect. According to a Johns Hopkins Medicine study, surgical “never events” occur at least 4,000 times every year in the U.S. The researchers estimated about 80,000 SREs in U.S. hospitals between 1990 and 2010.
Wrong body site surgery happens 20 times a week. According to the National Practitioner Data Bank (NPDB), there were 2,217 wrong-site surgical procedures in 13 years. However, only about one out of every ten wrong-site surgeries gets reported, leaving the actual number of wrong-site surgeries potentially much higher.
Causes of Wrong Body Part Surgical Errors
There are several potential causes of wrong site surgical errors, including problems with the process and health care systems. Common causes of these negligent surgeries include:
- Lack of surgery site verification
- Lack of a checklist
- Over-reliance on the surgeon alone
- Time pressures
- Lack of orientation and training
- Lack of proper staffing
- Inadequate patient assessment
- Inadequate care planning
- Multiple surgeons involved in the same procedure
- Multiple procedures on multiple parts during a single operation
- Failure to mark the correct operation site
- Noncompliance with procedures
- Failure to recheck patient information
Guidance for Reducing Wrong Site Errors
The Joint Commission is a nonprofit health organization that accredits hospitals and health care organizations. In 2004, the Joint Commission developed a Universal Protocol to prevent wrong site, wrong procedure, and wrong person surgery. This protocol was based on some of the most common causes of wrong site surgeries and simple steps to reduce these tragic errors. The Universal Protocol consists of 3 steps:
- Pre-procedure verification process
- Mark the procedure site
- Perform a time-out
The Universal Protocol mandate has largely been successful but has not totally eliminated the risk of wrong site surgeries. According to a study at the University of Illinois, researchers looked at the effectiveness of UP implementation for neurological wrong-site surgeries. After UP was implemented, the researchers concluded a statistically significant reduction in overall wrong site surgeries, with less frequent wrong-level spine surgery and only one case of wrong-side surgery.
Pre-Procedure Verification Process
The pre-procedure verification process is conducted to address missing information or discrepancies before the procedure begins. This process involves:
- Verify the correct procedure, correct patient, and correct site
- Involve the patient in the verification process, when possible
- Identify necessary items for the procedure
- Use a standardized list to verify the item availability, including relevant documentation, labeled diagnostic and radiology test results that are properly displayed, and any required blood products, implants, devices, special equipment
Mark the Procedure Site
The medical team should mark the procedure site when there is more than one possible location for the procedure. For bilateral surgeries, the site may not have to be marked, for example, removing both tonsils. Marking the procedure site can depend on the type of procedure, with the process involving:
- Mark the site before the procedure is performed
- Involve the patient in the site marking process, when possible
- Marking done by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed
- In some situations, site marking may be delegated to some medical residents, physician assistants (PAs), or advanced practice registered nurses (APRNs)
- Make the mark unambiguous and consistent throughout the organization
- The mark is sufficiently permanent to be visible after skin preparation and draping
- Use the organizations written, alternative process to ensure correct site operation when patients refuse site marketing or it is impractical to mark the site
Perform a Time-Out
The time-out step allows all those involved to take a pause before continuing with an invasive procedure, to make sure all the boxes have been checked and everyone is on the same page. The process includes:
- A time-out immediately before starting the invasive procedure or making the incision
- Designated member of the team starts the time-out
- Standard time-out procedure
- Involvement with the immediate members of the procedure team
- All members of the procedure team actively communicate during the time-out
- Team members agree, at a minimum, on the following: correct patient identity; correct site; and procedure to be done
- Document completion of the time-out
Discovering a Wrong Site Surgery
Many wrong site surgeries are discovered as soon as they are performed. Even as the surgeon is removing tissue or stitching up the patient, the doctor may suddenly realize their mistake. It may be too late to correct the error and some doctors may even try and ignore the problem until after the procedure is over.
Many wrong site surgeries are also discovered when the patient comes out of anesthesia. When the patient wakes up and looks down and notices bandages on the wrong side of the body, it can be very traumatic. Unfortunately, it may be too late to do anything about the surgical error. Instead, the patient will be forced to go through the procedure again to treat the correct area, requiring two surgeries, multiple anesthesia treatments, and extended recovery after surgery.
Delayed Discovery of Surgical Negligence
However, some wrong-site surgeries are not discovered until much later. Internal surgery may not be visible to the patient after recovery. It may take weeks or months before the patient discovers there was a serious mistake. For example, if a patient was set to undergo spinal surgery and the doctor operated on the wrong vertebrae, the patient may have no idea that the doctor made a mistake.
The patient, unaware of the mistake, may still complain of the same problem as before the surgery, with doctors putting the burden on the patient to prove their symptoms. Some patients even experience frustration by the doctors because the doctors blame the patient. It may take aggressive self-advocacy before further x-rays or scans discover that a surgical error was made.
Delayed Discovery and Statute of Limitations
The problem with delayed discovery of the problem is that it can conflict with the statute of limitations, which could limit the patient’s chance of recovery. The statute of limitations is the maximum time limit that a medical malpractice claim can be initiated in a civil court case. Each state sets its own statute of limitations and available exceptions or extensions.
In Maryland, the time limit to file a medical malpractice claim is the lesser of 3 years from the date of discovery, or 5 years from the date of injury. In Pennsylvania, an injury victim of medical malpractice must file a claim within two years of the date the injury occurred. However, under the Discovery Rule, a patient may have more time to file a medical malpractice lawsuit if the injury was discovered at a later time.
Preventing Wrong Site Surgeries
Patients and their families may need to take a very active role in their medical care to reduce the risk of a wrong site surgery. Some doctors and surgeons brush off patients’ concerns or dismiss their complaints without addressing their questions. With something as serious as a surgical procedure, make sure the medical team understands your concerns. Some steps you can take to reduce the risk of a surgical error include:
- Double-check all medical paperwork and forms
- Have a family member be prepared to ask questions if there is something you may have missed
- Talk to your doctor regularly to confirm the procedure and side where the procedure is to be done
- Check to make sure the surgical site is marked before surgery begins
What Happens After a Wrong Site Accident?
After a wrong-site surgery accident, it may be too late to go back and correct the error. You should consider talking to an experienced medical practice lawyer about your case, to make sure you get the care you need and recover damages for the negligent medical care. A medical malpractice claim can help your recover economic damages and non-economic damages, including:
- Medical bills
- Future medical care
- Lost income
- Loss of earning potential
- Pain and suffering
- Disfigurement and disability
An experienced law firm can help guide you through the complex medical malpractice process. Talk to experienced trial attorneys who can review your case, get expert medical reviews, and help you understand your legal options to file a claim against the surgeons, doctors, and hospitals responsible. Contact Gilman & Bedigian online or at 800-529-6162 for a free consultation.