A Connecticut women has filed a lawsuit against the Yale-New Haven Medical Center over a wrong-site surgery that was covered up by the hospital.
Last May, 60-year-old Deborah Craven went into surgery to remove a painful and potentially cancerous lesion on her eighth rib. Without Craven’s knowledge, a surgical trainee was added at the last minute to the surgical team. An attending physician at Yale was originally supposed to complete the surgery along with other members of the hospital staff.
Before Craven went into surgery, radiologists marked the eighth rib by placing metal coils on the rib and injecting a dye into the surrounding skin and tissue of the rib.
When Craven woke up from the procedure, she was still experiencing the same pain she had experienced before the surgery. An x-ray by hospital staff found that the surgery was performed on the seventh rib, not the eighth. Craven was not informed of this at the time and was only told by the surgical resident that “not enough rib” was removed during the original surgery and that she immediately needed a second surgery.
Once Craven found out that a surgical resident had been involved in the surgery, she requested that he be removed from the second surgery. But medical records showed that the resident was again allowed to joined the surgical team.
Craven did not find out until after the second surgery that the real problem was a wrong-site operation on her seventh rib. The lawsuit claims that the doctors were negligent in failing to perform surgery on the clearly marked surgical site and that the doctors further failed to perform an x-ray after the surgery to make sure the operation was successful. Craven claims the doctors attempted to cover up the mistake that was made by telling her that “not enough” rib was removed.
Wrong site surgery is surprisingly common, and studies have found that it may occur as often as 40 times a week in the United States. The Joint Commission, a non-profit organization that accredits health care organizations across the United States, has created procedures that hospitals can use to reduce the incidence of wrong-site surgery.
Causes of wrong-site surgery identified by the Joint Commission include:
Intake errors: or failing to correctly document the patient’s name, medical history, and operating instructions
Inconsistent use of site marking protocol, making it difficult to recognize a marked site, or leading to errors in the site-marking procedure (such as moving the patient to the operating room before marking the site)
Allowing someone other than the surgeon to mark the site: allowing the surgeon to mark the site will decrease errors. Following this procedure could have helped the surgeons at Yale-New Haven Medical center where the site was marked by a radiologist.
Failing to take a Time Out: the Joint Commission has created a procedure for a “Time Out” that surgical teams should take before performing a procedure. Time Out allows for the team to verify details of the patient and upcoming procedure, like the surgical site.
Senior leadership is not actively engaged: allowing other members of the hospital to take on unwarranted tasks. In the case of Deborah Craven, the surgical resident was allowed to tell the patient about the second surgery, and lied in the process.