Extreme Surgical Error Shows Never Events Still Happen
November 1, 2024 11 minutes read
By Greg Freeman
Executive Summary
A Florida surgeon mistakenly removed a man’s liver instead of his spleen, causing his immediate death. The case illustrates the need to prevent never events.
- The surgeon’s license has been suspended.
- Authorities are considering criminal charges.
- The incident raises questions about hospital culture.
A stunning surgical error in Florida is a reminder that never events still can happen and underscores the importance of a hospital culture that encourages clinicians to speak up when they suspect something is wrong. On Aug. 21, 2024, a surgeon began a hand-assisted laparoscopic splenectomy procedure but converted to an open procedure due to poor visibility caused by a distended colon. He mistakenly removed the patient’s liver, transecting the vena cava and causing catastrophic blood loss that resulted in Bill Bryan’s death, according to the Florida Department of Health.
Records indicate the surgeon, Thomas Shaknovsky, DO, claimed he did not realize his mistake and labeled the removed liver specimen as “spleen.” The error was not reported until a pathologist examining the tissue identified it as liver rather than spleen.
That raises questions about the hospital’s culture of safety and the staff’s willingness to report an obvious error, because staff later said they realized the mistake as soon as the liver emerged from the abdomen.
Although it may be difficult for hospital culture to overcome a surgeon who simply does not know anatomy, there is no indication in the documentation or subsequent interviews that any team member spoke up to question the surgeon’s actions in the moment.
Shaknovsky told the patient’s wife afterward that the “spleen” was so diseased that it was four times larger than normal and had “migrated” to the wrong side of the body, says the Bryan family’s attorney, Joe Zarzaur, JD, in Pensacola, FL. (Zarzaur provided details about the case in an online press conference and on the firm’s website at https://zarzaurlaw.com/surgeon-removes-the-liver-of-the-patient/)
This was not the first time the surgeon committed a wrong-site error, Zarzaur reports. Records indicate that in 2023 Shaknovsky mistakenly removed part of a patient’s pancreas instead of performing the intended adrenal gland resection, he says. The patient died and the resulting malpractice case was settled. Shaknovsky remained at the hospital where he would later operate on Bryan.
The hospital issued a statement saying it is thoroughly investigating the Bryan incident. The Bryan family has not filed a medical malpractice lawsuit yet because Florida law requires a “pre-suit period” for possible resolution without a lawsuit, Zarzaur says. That often takes six to nine months, he says.
The Walton County Sheriff’s Office issued a statement saying Bryan’s death could lead to criminal charges.
Emergency License Suspension
The Florida Department of Health suspended Shaknovsky’s medical license with a 21-page emergency order that says, “Dr. Shaknovsky’s blatant disregard for the truth, falsification of an operative report, and attempt to convince OR [operating room] staff to acquiesce to his version of events is a breach of the public trust. Dr. Shaknovsky’s dishonesty cannot be contained to only operative reports; it colors every aspect of the practice of osteopathic medicine.”
The order goes on to say that the public must be able to trust Shaknovsky’s description of patient care but “That trust is irrevocably broken. Therefore, there is no restriction that can adequately protect the public from an osteopathic physician who is willing to lie and pressure others to lie on their behalf.” (The emergency order is available online at https://zarzaurlaw.com/wp-content/uploads/2024/09/emergency-sus.pdf)
The suspension order includes an account of the surgery and subsequent investigation that suggests Shaknovsky falsified documentation.
“Dr. Shaknovsky documented that during the code, he packed the abdomen with sponges, was able to control the ruptured aneurysm with a surgical clamp, transected the splenic vein and artery, and removed the spleen from Patient W.B.,” the order says. “However, in a later interview, Dr. Shaknovsky claimed that he had never been able to control the aneurysm, but instead decided to complete the splenectomy in a last-ditch effort to control the bleeding after Patient W.B. had already been in cardiac arrest for fifteen minutes. Dr. Shaknovsky claimed that he fired the stapling device blindly into the abdomen and removed an organ that he believed to be a spleen.”
The order says Shaknovsky blamed his “shock and the chaos of the situation” for the error.
“Dr. Shaknovsky’s Operative Report contained deceptive and untrue statements that failed to accurately describe what occurred in the procedure,” the order says. “The witnesses in the OR consistently and clearly recounted a summary of events that is markedly more troublesome than Dr. Shaknovsky’s written account of what occurred.”
OR team members told investigators that when the abdomen was opened, a megacolon immediately burst out of the cavity and disrupted visibility. Shaknovsky identified a vessel he intended to cut and noted that he could feel it pulsing, the order says. He told an assistant, “That’s scary.”
He then fired a surgical stapling device on the vessel. The patient immediately hemorrhaged and went into cardiac arrest. Shaknovsky continued working in the abdomen as the rest of the team worked the code, dissecting further “even though the abdomen was full of blood and there was no visibility. He did not ask staff for a clamp or cauterizer.” It was during this period that he fired the stapling device blindly and removed a 2,106-gram liver and labeled it as a spleen. A normal spleen weighs 70-200 grams, the order notes.
“The staff looked at the readily identifiable liver on the table and were shocked when Dr. Shaknovsky told them it was a spleen,” the order says. “One staff member felt sick to her stomach.”
The order notes that the staff member responsible for labeling the specimen knew it was not a spleen but followed Shaknovsky’s instruction to label it as such.
After the patient was declared dead, the surgeon left the OR but returned three times, stating each time that the bleeding was caused by the patient’s splenic artery aneurysm rupturing. “The staff in the room felt that Dr. Shaknovsky was attempting to convince them that this is what occurred, even though they witnessed something different,” the order says.
Inexcusable Error
The case is difficult when considering how the outcome might have been prevented, because it is unclear if the OR team had any opportunity to voice concerns before the fatal error was made. If so, the hospital should review its culture of safety and how much staff feel empowered to speak up, says Cynthia Hernandez, JD, managing attorney with Hernandez Family Law & Mediation in Tampa Bay, FL.
“A wrong-site surgery like removing the wrong organ is inexcusable and threatens the foundation of trust in the patient-physician relationship,” she says. “Nurses are patient advocates and should feel empowered to speak up if something seems amiss. I’ve seen the devastating effects when they don’t.”
The hospital will likely face a negligence lawsuit, as will the surgeon who made the error, and they should expect to pay sizable damages to the family, Hernandez says. Other hospitals must reexamine their own procedures to prevent similar catastrophic errors, she says.
“There is simply no room for error in surgery. As attorneys, we pursue justice for clients harmed by neglect. As citizens, we place enormous trust in physicians and hospitals,” Hernandez says. “They must do better to earn and maintain that trust through an uncompromising commitment to patient safety.”
Staff Must Speak Up
Situations like this highlight the need for a culture where everyone feels empowered to speak up if something is wrong, says Saami Khalifian, MD, a dermatologist in Encinitas, CA.
“Clear policies on pre-op checks, checklists, and timeouts are key but only work if followed properly,” he says. “Regular training and feedback, both positive and negative, build a culture where patient safety comes first.”
The incident should prompt other hospitals to review policies and procedures, retrain staff, and ensure best practices are followed, he says.
“Patient safety can’t just be an aspiration but an operational reality where mistakes are nearly impossible,” he says. “While regulations require time and money, preventing adverse events like wrong-site surgery saves lives and reduces costs. The best care demands an ongoing commitment to safety through policy and culture. There are no excuses for errors this serious.”
As a surgeon, Khalifian says he has seen how preventable errors can slip through the cracks, even with strict protocols in place.
“The surgical assistants and nurses should have spoken up the moment the wrong organ was addressed. A culture where all team members feel empowered to raise concerns without fear of retaliation is essential,” he says. “Policies and procedures are only as good as their implementation. Checklists, timeouts, and site marking must be taken seriously on every case, no matter how routine.”
Khalifian notes that physicians must create an environment where others feel comfortable questioning their actions and decisions. Regular training, simulation drills, and debriefs after any near misses help reinforce best practices, he says.
“The consequences in this case are grave, and litigation is almost certain. The surgeon faces potential loss of license and criminal charges. The hospital risks fines, lawsuits, and damaged reputation. My hope is that this serves as a sobering reminder to reexamine safety measures and team dynamics,” he says. “One mistake should not cost a life, and one life lost is one too many. Our duty is to learn from errors, strengthen systems, and build a culture of collective vigilance against complacency. We owe it to our patients, and we owe it to ourselves as physicians.”
The facility clearly failed to have proper safeguards and a culture promoting speaking up, says Chris Lyle, JD, an attorney with CompFox, a company in Orange County, CA, that works with workers’ compensation cases.
“In my experience, errors like wrong-site surgeries often happen due to poor communication and assumptions. The surgeon likely did not give a proper briefing, and the staff felt unable to question the surgeon’s actions. I have seen many cases where staff do not feel empowered to speak up to physicians, especially surgeons,” he says. “The facility is liable for not addressing this issue and ensuring safeguards like pre-surgery briefings, checklists, and encouragement of all staff to voice concerns.”
Other hospitals must reevaluate their culture of safety, implement strict policies for confirming procedures, encourage all staff to voice concerns, and avoid assumptions of any one person’s infallibility, Lyle says.
Breakdown in Procedures?
The first breakdown likely occurred in the preoperative planning and verification stages, Maria Knöbel, MBBS, ARCS, Dip, BSLM, IBLM, MRCGP, medical director of Medical Cert UK in London, England. Before any surgery, it is important to follow strict protocols that ensure the correct site and procedure are confirmed multiple times — such as on which side of the body to locate the spleen, she says.
This includes a thorough review of medical records, imaging, and physical markings on the patient’s body.
The surgical team should have conducted a time-out immediately before the incision, during which they all confirm the site, the procedure, and the patient’s identity, she says. Any discrepancies should have been caught at this point. If the liver was addressed instead of the spleen, it indicates that these safety checks either were not followed or were insufficient, Knöbel says.
“This incident is a stark reflection of the hospital’s safety culture, or perhaps a lack thereof. A facility that prioritizes safety would undoubtedly have comprehensive systems in place to prevent such a catastrophic error. It’s not merely a matter of having policies on paper; there must be an environment where staff feel empowered to voice concerns if something appears amiss,” she says. “Such mistakes indicate that either the policies are insufficient, or the team dynamics did not promote open communication. This situation casts doubts on the hospital’s overall dedication to patient safety, including whether the staff are overworked, rushed, or if taking shortcuts has become the norm.”
Other hospitals should take this as a wake-up call to reevaluate their own safety protocols and team communication structures, she says.
“While the time-out process is a widely accepted standard, it’s clear that even this isn’t enough if the culture doesn’t support vigilance at every step,” she says. “Hospitals should implement regular training simulations for the entire surgical team, promoting a culture where even junior staff feel comfortable raising concerns.”
System Errors Likely
An error as extreme as the one that killed Bryan almost certainly is the result of systemic errors and not only a poorly skilled surgeon, says Oliver Morrisey, JD, owner and director of Empower Wills & Estate Lawyers in New South Wales, Australia.
“This tragic incident, where a surgeon mistakenly removed a man’s liver instead of his spleen, underscores just how devastating surgical errors can be. For something this catastrophic to occur, there were clearly multiple systemic failures. The fact that no one on the surgical team spoke up raises serious concerns about the communication dynamics within the operating room,” he says. “A well-functioning team would encourage open dialogue, where even the junior members feel empowered to voice concerns. If no one felt able to stop the surgery or question the actions taking place, it indicates a breakdown in both individual responsibility and team culture.”
Morrisey says the incident speaks volumes about the facility’s safety culture. Policies and procedures are only as effective as the people who implement them, he says, and in this case it seems the safeguards that should have been in place were either not followed or not enforced properly.
“Mistakes of this magnitude don’t happen in a vacuum. There’s usually a chain of smaller errors and oversights that culminate in a fatal outcome. The fact that such an egregious error occurred suggests there might be an underlying issue with complacency or insufficient checks within the institution,” Morrisey says. “Hospitals that prioritize patient safety typically have rigorous verification steps, such as the time-out procedure, where the entire surgical team confirms the details of the operation. The failure to prevent such a grave mistake shows that the systems in place were inadequate or inconsistently applied.”
The consequences for the surgeon and the hospital are likely to be severe, he notes. For the surgeon, aside from the civil and possibly criminal charges being considered, there’s the potential loss of medical license and the end of his career in healthcare, he says.
“For the hospital, beyond the legal ramifications, the damage to its reputation could be catastrophic. Patients need to trust that they are in safe hands, and incidents like this erode that trust, not just for the hospital in question but for the healthcare system as a whole,” Morrisey says. “Financial penalties, compensation claims, and a likely overhaul of internal procedures will follow, but the most lasting damage could be to public confidence.”
Other hospitals should take this as a wake-up call, he says.
“Mistakes like this don’t just happen out of nowhere. They are often the result of systemic issues that build up over time. Facilities need to continually reassess their safety protocols, not just at the administrative level, but on the ground, where surgeries and other critical procedures take place,” Morrisey says. “Ensuring that every team member feels empowered to speak up, that verification processes are robust, and that there’s a culture of double-checking rather than assuming, are lessons every hospital should internalize from this tragedy.”
Sources
- Cynthia Hernandez, JD, Hernandez Family Law & Mediation, Tampa Bay, FL. Telephone: (813) 841-2933.
- Saami Khalifian, MD, Encinitas, CA. Telephone: (760) 766-7546.
- Maria Knöbel, MBBS, ARCS, Dip, BSLM, IBLM, MRCGP, Medical Director, Medical Cert UK, London, England. Email: [email protected]
- Chris Lyle, JD, CompFox, Orange County, CA.
- Oliver Morrisey, JD, Empower Wills & Estate Lawyers, New South Wales, Australia.
Telephone: 1300 414 844. Email: [email protected]
Greg Freeman has worked with Relias Media and its predecessor companies since 1989, moving from assistant staff writer to executive editor before becoming a freelance writer. He has been the editor of Healthcare Risk Management since 1992 and provides research and content for other Relias Media products. In addition to his work with Relias Media, Greg provides other freelance writing services and is the author of seven narrative nonfiction books on wartime experiences and other historical events.
A stunning surgical error in Florida is a reminder that never events still can happen and underscores the importance of a hospital culture that encourages clinicians to speak up when they suspect something is wrong.
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