Surgical Mishaps: Wrong-Site Operations

A Rhode Island doctor was reprimanded for operating on the wrong side of brain.

ByABC News via logo
January 8, 2009, 1:22 AM

Aug. 9, 2007 — -- An 86-year-old man was taken into surgery at Rhode Island hospital last week to have blood removed from his brain's left side.

He underwent surgery, but something went terribly wrong, and it had nothing to do with the man's health. The surgeon had made a glaring mistake: He'd operated on the wrong side of the man's brain.

Compounding the potentially dangerous error was the fact that this was the second time the doctor had made such a mistake this year.

"The surgeon, although he had seen the CAT scan in advance, he misrembered the side of the surgery," said Dr. Robert Crausman of the Rhode Island Department of Health. "Part of the picture here is an operator error."

The patient, whose name has not been released, is in stable condition.

The doctor was suspended by the health department, which also ordered an evaluation. The doctor was not sanctioned after the first mistake because so much of the blame belonged to the hospital, which had a host of system problems.

"Wrong-site" surgeries -- when a doctor operates on the wrong body part or even patient -- occur between 1,300 and 2,700 times a year in the United States, according to an Archives of Surgery study.

In Pennsylvania alone, wrong-site surgeries happen once a week on average.

"Wrong-site surgery should never happen," said Dr. John Clarke, who oversees the Pennsylvania Patient Safety Authority. "I don't think you have to be an advanced society to tell right from left."

The group recommends patients ask the doctor or nurse before surgery to mark the place to be operated upon.

"The patient should not be shy about speaking up on their own behalf," Clarke said. "They are the last defense before a medical error."

He said while patients are awake they should make sure the surgeon is involved in the marking.