By Steven DiJoseph
Serious surgical mistakes often begin as simple errors that go undetected. Reading the wrong patientÃ¢â‚¬â„¢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.
Apparently, the facts leading up to the removal of the wrong (healthy) kidney of a 63-year-old cancer patient followed this familiar, but tragic, pattern.
The man, John Heron, gave an exclusive interview to sundaymail.co.uk that reveals the type of Ã¢â‚¬Å“comedy of errorsÃ¢â‚¬Â that often produces the occurrence of what is known as Ã¢â‚¬Å“wrong-site surgery.Ã¢â‚¬Â
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 HeronÃ¢â‚¬â„¢s left kidney.
Following the surgery, Heron was even told that he was Ã¢â‚¬Å“a lucky man.Ã¢â‚¬Â 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.
Now, as the result of this Ã¢â‚¬Å“disastrousÃ¢â‚¬Â mistake, Heron faces years of dialysis and an uncertain future. He must await a donor kidney, which could take two or more years and he must undergo additional surgery to remove the tumor and cancerous portion of his left kidney.
Even under the best of circumstances Ã¢â‚¬â€œ should a family member prove to be a compatible donor Ã¢â‚¬â€œ the surgery would have to wait for at least two years because of the cancer.
Mr. Heron was admitted to Ayr Hospital earlier this month after doctors discovered a tumor on one of his kidneys. What followed was characterized by his family as a “disastrous” mistake and Ã¢â‚¬Å“disastrous professional errors that should never have happened.Ã¢â‚¬Â
The family is Ã¢â‚¬Å“devastatedÃ¢â‚¬Â and wants Ã¢â‚¬Å“to ensure that everything is now focused upon providing the best medical experience and care for my father.”
The executive medical director of NHS Ayrshire and Arran apologized to the family on behalf of the hospital, saying: “It is with deep regret I can confirm a patient had a healthy kidney removed. The board at NHS is now planning future medical care for Mr. Heron.
“Our thoughts are with the patient and family, to whom we apologize for this tragic error.”
Although treatment for a gallstone problem had revealed a small cancerous tumor on the left kidney, and surgery had been scheduled for March 8, the GPÃ¢â‚¬â„¢s letter and CT scan report identified the right kidney as the one with the tumor.
Instead of waiting to examine the X-rays, the surgeon, Riza Murat Gurun, decided to proceed with the operation since Heron had been Ã¢â‚¬Å“prepped.Ã¢â‚¬Â
As we previously reported, in September of last year, two similar cases revealed that such Ã¢â‚¬Å“wrong-site surgeryÃ¢â‚¬Â 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.
The Daily Mail reported Mrs. Patterson as stating: Ã¢â‚¬Å“No one can understand what itÃ¢â‚¬â„¢s like to be told you have a disease that could kill you. Then to be told it was a mistake is just disgusting. They canÃ¢â‚¬â„¢t bring my breast back Ã¢â‚¬â€œ I am disfigured for life.Ã¢â‚¬Â
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 manÃ¢â‚¬â„¢s perfectly healthy kidney instead of his cancerous one.
Another similar error occurred in the UK in January 2000 when two surgeons removed a manÃ¢â‚¬â„¢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 Ã¢â‚¬Å“wrong way round.Ã¢â‚¬Â He realized something had gone wrong when, two hours after the surgery, the anesthetist told him that the man had not produced any urine
The surgeon then tried to “rescue” the good kidney so that it could be replanted but it had already been put in sterilizing agent and that was not possible. An attempt to get the manÃ¢â‚¬â„¢s diseased remaining kidney to work was also doomed.
Five weeks after the botched surgery the 69-year-old man died on 1 March 2000.
While one would hope these types of horrific mistakes were rare, the truth is they are not.
From 1985 to 1995 alone, 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.
This error, however, wasted two donor hearts and four donor lungs, caused a young girl to lose her one chance at a normal life, inflicted two weeks of unimaginable pain and suffering on the child including the need for a second transplant operation, and it killed her.
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 Mr. HeronÃ¢â‚¬â„¢s case reveals, 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.