Wrong-site surgery traced to lack of timeout

A surgeon’s wrong-site error on a patient’s brain happened because he failed to perform a timeout before the procedure, according to a recent court decision that also describes how the physician tried to hide his error and did not report the sentinel event to administrators.

After suing the hospital and surgeon, the plaintiff sued the university employing the doctor, which put the case in the hands of the Arkansas State Claims Commission, which handles claims against state agencies. The commission members determined recently that doctors and administrators of the hospital the surgeon was employed by were negligent because they failed to follow the hospital’s timeout policy. Furthermore, they said the surgeon and other team members tried to cover up their error and did not report it properly.

Court records indicate that a 15-year-old boy underwent an operation in 2004 to remove a brain lesion thought to be the cause of a seizure disorder. The surgery took place at a children’s hospital and was performed by a surgeon employed by a university hospital.

Interestingly, a newspaper reporter was present in the OR. The hospital had invited the reporter to observe the procedure and take photographs, with the parents’ permission. The surgeon began the procedure without a timeout and made an incision into the left side of the brain, when, in fact, the correct site was the right side. When the surgeon realized his error, court documents indicate, he had the reporter removed from the room before the staff repositioned the patient.

The surgeon completed the procedure on the right side of the brain. Afterward, the court documents say, the surgeon told the patient’s family that he had started the procedure on the wrong side but that he had realized his error before doing any damage to the brain. The family found out the truth 15 months later when an MRI showed that both sides of the brain had been operated on.

In the subsequent medical malpractice lawsuit, the plaintiff was awarded $20 million from the hospital where the surgery took place, but the circuit judge overseeing the case reduced the amount to $11 million. The surgeon settled with the parents for $1 million.

The commission reviewed the testimony from the original malpractice case and determined that the surgeon and his employer were at fault.

The surgeon “admitted that he started the procedure on the wrong side of the brain, but denied that he removed any part of the left amygdala, stating that he merely did a biopsy on the left side,” the commission wrote. The surgeon “acknowledged that he acted below the standard of care” and “further admitted that he failed to do a complete, consistent, and accurate charting of [the patient’s] history and physical,” the commission wrote.

The surgeon explained that a “sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or risk thereof, and that there was no question that what happened with [the patient] was a sentinel event,” the commission wrote, adding that the surgeon “stated that the procedures that follow a sentinel event did not occur in this instance, including having a hospital administrator present during discussions with the family.”

The surgeon “told other doctors and people around the hospital that he started the surgery on the wrong side, that no harm was done to the brain, and that he then operated on the correct side,” the commission wrote. The surgeon “could not recall whether a timeout occurred prior to [the patient’s] surgery,” the commission wrote. The court documents are available online at http://tinyurl.com/zydr7t6.

Editor’s Note: This article was updated in June 2018.