California Hospital Announces New Rules after Opening Wrong Side of Child’s Skull during Brain Surgery

By Steven DiJoseph

Although officials at Children’s Hospital of Orange County (“CHOC”) claim that the “error” was the first of its kind in the hospital’s 42-year history, in the case of “wrong-site surgery” mistakes, one error is too many. As a result, the hospital has announced it will implement new operating room rules designed to prevent any such errors in the future.

After an investigation, the California Department of Health Services found that on January 13, CHOC surgeons opened the wrong side of a child’s skull during an operation to remove a brain tumor. The agency’s report noted that the doctors involved failed to observe the “time out” before the surgery and failed to mark the operation site on the child’s head.

The error was discovered when no tumor was found under the portion of skull initially removed. At that point, the doctors replaced the section of skull removed by mistake and proceeded to the correct operative site where the tumor was located and removed.

Reportedly, the child suffered no complications as a result of the error (beyond those immediately attributable to the wrong-site surgery itself, of course).

The Department of Health Services also found that the doctors failed to document the wrong-site surgery in the child’s hospital chart. The hospital did, however, notify the state thereby prompting the investigation.

The agency concluded that the mistake may have been the result of a doctor moving the operating table in order to make room for an assistant surgeon. This may have caused the operating team to become disoriented. Although the child was under the care of CHOC doctors, the incident occurred at nearby St. Joseph Hospital, where CHOC contracts for additional operating space.

The hospital has until April 17 to submit a “plan of correction” to the Department of Health Services detailing the changes it intends to make to prevent similar occurrences.

CHOC announced that in the future, cutting instruments will be removed from the immediate operating area until surgeons complete the required “time out” in order to identify the correct operative site and that the surgical team will make certain the proper area to be operated on is clearly marked.

As previously reported, serious surgical mistakes often begin as simple errors that go undetected. Reading the wrong patient’s hospital chart or test results, failing to look at an X-ray or looking at one backwards, improperly filled out forms, or marking the wrong surgical site have all resulted in catastrophic mistakes in the operating room.

Sometimes the mistake is discovered during surgery; however, in most cases the error is only revealed afterwards. In either case, it is usually too late to undo the damage.

The California case only serves to confirm that these serious errors can usually be traced back to relatively minor mistakes.

This was also the case with respect to the facts leading up to the removal of the wrong (healthy) kidney of a 63-year-old cancer patient in the UK less than two weeks ago.

The man, John Heron, gave an exclusive interview to that reveals the type of “comedy of errors” that often produces the occurrence of what is known as “wrong-site surgery.”

In the interview, Mr. Heron stated that before the surgery he clearly told doctors that the pain he was experiencing was on his left side. His right side had already been marked, however, and he was told not to worry.

At the time, his doctors had not reviewed X-rays that clearly showed the cancerous tumor was on Heron’s left kidney.

Following the surgery, Heron was even told that he was “a lucky man.” The next day, however, he was told the terrible news after the pathology lab found the kidney that had been removed to be completely healthy.

In September of last year, we reported on two similar cases that revealed “wrong-site surgery” and other horrific surgical errors occur all too frequently regardless of the country or the quality of the hospital or doctors involved.

In the first case (just then being reported by news sources in the UK), 52-year-old Marjorie Patterson had a routine mammogram which supposedly showed a suspicious shadow. After an MRI and biopsy, she was told by telephone that she had an aggressive type of breast cancer.

When doctors advised her that a mastectomy was needed to save her life, she agreed, and the surgery was performed. Three weeks later, doctors admitted the biopsy they had examined belonged to another patient and that Mrs. Patterson never had cancer.

In September, the New York State Health Department announced it was launching an investigation into what happened at Phelps Memorial Hospital Center in Sleepy Hollow, New York, where surgeons removed a man’s perfectly healthy kidney instead of his cancerous one.

Another similar error occurred in the UK in January 2000 when two surgeons removed a man’s healthy kidney instead of his diseased one. One of the doctors told a disciplinary panel that he had collected X-rays but had read them the “wrong way round.” He realized something had gone wrong when, two hours after the surgery, the anesthetist told him that the man had not produced any urine. Five weeks after the botched surgery the 69-year-old man died.

From 1985 to 1995, the Physicians Insurers Association of America (PIAA) counted 225 claims for wrong-site surgery by its 110,000 doctors in the United States.

Some other notable cases that came about because of simple mistakes include one in 1995, at Tampa’s University Community Hospital, where a surgeon amputated the wrong leg of 51- year-old Willie King.

The 59-year-old mother of a prominent Indian film star was brought to Sloan-Kettering Cancer Center in New York to have a malignant brain tumor removed. The neurosurgeon operated on the wrong side of her brain. The woman now suffers from severely impaired vision and no awareness of her left side. (Washington Post, 7/25/95).

A surgeon at Butterworth Hospital in Grand Rapids, Michigan, cut off the wrong breast of a 69-year-old cancer patient during a mastectomy. (USA Today, 3/27/95).

A surgeon in Boston removed the wrong kidney from a patient after failing to check x- rays that would have revealed this tragic error. (Boston Globe, 6/1/96).

In a particularly tragic case, Jesica Santillan, a 17 year-old girl from Mexico who was smuggled into the United States to receive treatment for a life-threatening heart condition, waited three years for a donor heart and lungs to be found.

When the heart and lung transplant, which was supposed to save her life, was finally performed, her condition only worsened. It was then discovered that the heart and lungs she received did not match her blood type.

Jesica required a second transplant operation two weeks later but the damage to her brain and other organs was irreparable. Jesica experienced brain damage and kidney failure, was ultimately declared brain dead, and removed from a respirator.

After this tragedy, Duke University Hospital, which admitted it had made an inexcusable medical mistake in cross-checking blood types, initiated a three-person verification system to ensure that the blood type of the donor and recipient match.

A 67-year-old man named Hurshell Ralls went into surgery for bladder cancer and, while under anesthesia, the surgeon removed his penis and testicles because he concluded that the cancer had spread to the penis.

No one had ever discussed the possibility of such radical additional surgery with Mr. Ralls who was shocked to learn what had happened to him at a time when he was unable to make a conscious decision about the removal of his penis and testicles. Later, after examining a tissue sample, another doctor concluded that Ralls never had cancer of the penis.

In May of 2002, Linda McDougal was diagnosed with breast cancer and underwent a double mastectomy at the United Hospital of St. Paul Minnesota. After the surgery, McDougal was told that she had never had cancer. Apparently, her slides had been mixed up with those of another patient.

As the CHOC case and many of the others reveal, these tragic, inexcusable errors continue to occur at even the most prestigious hospitals. Simple mistakes and failures to obtain or check critical information repeatedly act to undo even the best safety procedures that are supposed to guard against catastrophic surgical errors.

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