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'Wrong-site' surgical mistakes are rare, preventable

A surgical procedure to relieve pressure was performed on the wrong ear of a 10-year-old boy at All Children's Hospital in St. Petersburg in 2007.

The wrong patient at Tampa General Hospital was brought in for heart catheterization in 2008.

Radiation was delivered to the wrong side of a patient's neck at Tampa's Moffitt Cancer Center in 2006.

These medical mistakes belong to a rare and completely preventable category of errors known as wrong-site surgeries. Experts and doctors agree they should never happen, but struggle with the realities of human error.

Timeouts before the first cut, body parts marked with permanent ink, surgical checklists — step after step has been put in place in recent years to better safeguard patients. And yet, wrong-site errors still happen.

In the 10-month period ending in April, the Florida Board of Medicine disciplined 34 doctors for wrong-site surgeries, roughly on par with the 41 actions taken in the previous year. Just this month, it fined the physician who made the wrong ear incision at All Children's. And another 51 wrong-site cases now await disciplinary action.

One of the nation's most notorious cases of wrong-site surgery occurred in Tampa, when patient Willie King had the wrong foot amputated in 1995 at University Community Hospital. A diabetic, he died in 2001 from a blood clot.

Today, wrong-site errors rarely are so egregious. But they still can be serious, like the case involving a South Florida surgeon who in 2007 removed the kidney, instead of the gallbladder, of an 83-year-old man. Board members fined him $5,000 this month, saying they found his error understandable after seeing how the patient's scar tissue and abnormal anatomy made it difficult to identify the proper organ.

"In the beginning with the wrong sites, you were getting the really crazy ones, like the wrong limb, the really outrageous kind of stuff," Ed Tellechea, the Board of Medicine's legal counsel, later told members during a training session in Fort Lauderdale.

"The cases that you're seeing now are more nuanced," he said, but that can make it "harder from a discipline perspective."

Florida's error rate for wrong-site surgery — about one in 100,000 procedures — is low considering the millions of procedures annually, said John Beebe, a businessman and former member of the Board of Medicine who studied the issue extensively.

"It is always the goal of the Florida Board of Medicine to eliminate wrong-site surgery but it's also the goal of the (Federal Aviation Administration) to eliminate plane crashes," Beebe said. "Do they still occur? Yes.

"Even if we are lucky enough to eliminate it to zero in one year, that's probably not sustainable," he said. "Because if humans are involved, they will make errors."

• • •

Before the first incision, surgeons in Florida are required to take a timeout. They must confirm they have the right patient, the right procedure, the right surgical site. The pause rule, as it's known, was adopted by the Board of Medicine in 2004 and reflects nationally followed safety standards.

But it wasn't enough to prevent the error involving the 10-year-old boy at All Children's Hospital.

The boy's right ear was correctly marked for a procedure to relieve fluid buildup, state records indicate. However, Dr. Peter Orobello, a pediatric ear, nose and throat specialist, cut the left ear, inserting a small tube before realizing his mistake.

Orobello corrected his error immediately, records show, and informed the patient's family.

"In the 22 years of the otolaryngology program at All Children's Hospital we have had one case in 2007," Orobello said in an e-mail sent through his lawyer. "With the excellent systems in place, this was identified in surgery, corrected, no harm came to the patient and no claim was filed."

He did not say how the error happened. As discipline, he agreed to pay a $7,500 fine.

All Children's Hospital officials say they have for many years followed national patient safety standards, including a timeout established by the Joint Commission, the hospital accrediting group. They use a safety checklist tied to the electronic medical record in the operating room.

• • •

In any workplace, mistakes happen. But inside Catheterization Lab No. 4 at Tampa General Hospital, the stakes are particularly high.

In May 2008, Dr. John Thompson Sullebarger was scheduled to perform a heart catheterization, in which a thin flexible tube is inserted into a heart chamber for diagnosis or treatment. The procedure was indicated in the medical chart of the patient sent into the cath lab.

But en route, two patients' medical records had gotten mixed up, state records show. And the Spanish-speaking patient who ended up before Sullebarger erroneously acknowledged himself as the other patient to a lab technician.

His identity bracelet had his real name, but no one seems to have checked it.

Sullebarger took the required time-out, but only during the heart catheterization did he realize he had the wrong patient, according to state records. He stopped the procedure immediately, documented the error and informed the patient and his family. State records do not indicate that he suffered lasting effects from the procedure, but do say he was not billed for it.

A year later, Sullebarger was fined $12,500 by the Board of Medicine.

Now chief of the cardiology section at TGH, Sullebarger didn't return calls for comment, nor did hospital officials.

• • •

When he was the chairman of surgery at the University of South Florida medical school, Dr. Richard Karl was contacted by surgeons involved in wrong-site cases about the community service part of their discipline. He says he asked them the obvious question: How did this happen?

"They all said, 'I marked the correct limb, then they washed it off, then they turned the patient over, then they all watched me incise the wrong limb,' " he said. "There was a kind of we-they feeling."

Such systemic problems, he noted, are rooted in a medical culture where the surgeon is the boss and others may not feel they have the authority to speak up.

At Moffitt Cancer Center, where Karl now is the physician safety officer and a gastrointestinal surgeon, checklists are part of the answer. Before a patient goes into the operating room, the surgical staff check off that they have the right equipment, the right X-rays, that the procedure matches the consent form.

Karl says everyone he knows works doggedly to prevent errors — both for their patients and themselves.

"What surgeon in the world gets up in the morning with the intent to have something like this happen?" Karl said.

Letitia Stein can be reached at or (813) 226-3322. For more health news, visit

Patients: What to do to prevent wrong-site surgery

• Ask to have your surgical site marked with a permanent marker. Request to be involved with marking the site. This usually happens when you're awake, but you can ask a family member, friend or staff member to check that everything is done correctly if you're under anesthesia.

• Health care workers may ask who you are, what kind of surgery you're having and the body part targeted in surgery. They aren't just making conversation. These checks help to ensure your safety. Give detailed responses: "My name is Jane Smith. I'm here to have my left knee replaced."

• Ask someone you trust to be with you at the hospital or surgical center. Make sure they know the details of your planned procedure.

• Don't be afraid to ask questions. Speak up if you have concerns.

Source: the Joint Commission

'Wrong-site' surgical mistakes are rare, preventable 06/20/10 [Last modified: Monday, June 21, 2010 10:13am]
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