Surgeon Who Erred with Liver Suspended in Second State
December 1, 2024 5 minutes read
By Greg Freeman
The surgeon whose license was suspended in Florida for a shocking medical error has had his license suspended in Alabama for that and other incidents. Thomas Shaknovsky was performing a splenectomy procedure at a Florida hospital when he mistakenly removed the patient’s liver, transecting the vena cava and killing the patient, according to the Florida Department of Health. The surgeon claimed he did not realize his mistake at the time. (For more information on this case, see the November issue of Healthcare Risk Management.)
The Florida Department of Health suspended Shaknovsky’s medical license with a 21-page emergency order. On Oct. 24, the Alabama Medical Licensure Commission also issued an emergency suspension. Alabama and Florida are the only states in which Shaknovsky held active medical licenses, according to attorney Joe Zarzaur, JD, in Pensacola, FL, who is representing the family in the Florida incident.
The Alabama suspension stems from the Florida death, another incident in which the surgeon mistakenly removed part of a patient’s pancreas instead of performing the intended adrenal gland resection, and the treatment of a third patient who died after surgery in July 2023. She was scheduled for an ileostomy, but Shaknovsky performed a bowel resection that resulted in perforation, the suspension order states. It says Shaknovsky “exhibited an inability to practice medicine with reasonable skill and safety due to a lack of basic medical knowledge in his treatment” of the three patients. The scenarios created by this surgeon are frightening, says David W. Holub, JD, an attorney in Merrillville, IN.
The mistaken liver removal alone should result in civil liability for the surgeon and the hospital that authorized the surgeon to perform surgery, he says. It also quite possibly will result in criminal charges against the surgeon, he says, since the local sheriff’s office announced it is investigating.
“The last time I encountered a similar scenario was about 30 years ago. A surgeon removed several vertebrae from the patient’s spine, resulting in immediate paralysis,” he says. “Upon investigation, it was determined that the surgeon was addicted to a controlled substance. At the time of the surgery, he was having a hallucinatory episode, which caused him to believe that his surgery would improve the patient’s condition.”
Eventually, that surgeon was convicted of assault and battery and sentenced to prison, Holub says.
There should be an immediate alcohol and drug test administered to any surgeon who commits such errors, Holub says.
“You must consider that, unless the surgeon learned nothing in medical school, he or she would know the difference between a liver and a spleen on simple observation,” he says. “The organs, anatomically, are in different locations in the body.”
Furthermore, the hospital that authorized the surgeon to perform surgery would have to answer for many things, including what procedures were in place to confirm the surgery to everyone before surgery began, he says. There would seem to be no justification in any event ever to remove a patient’s liver unless there is going to be a transplant, he notes.
“If, before raising a scalpel, the surgeon announced, ‘Now we are going to remove this patient’s liver,’ you would expect everyone to tackle the surgeon and confiscate the knife,” Holub says. “If the announcement was, ‘Now we are going to remove the patient’s spleen,’ others in the room should have become suspicious when the surgeon began cutting on the wrong side of the chest that something was terribly wrong and interrupted the surgery.”
Any nurse, anesthesiologist, or any other tech assisting in the room should have “screamed out to the surgeon to stop if it was observed that the surgeon was removing the patient’s liver,” he says.
Holub acknowledges that it would be difficult to establish protocols that would eliminate this type of gross mistake. He questions whether the surgeon’s credentials were properly checked and whether everyone in the operating room agreed to the type of surgery that was going to be undertaken.
“In the case I described that led to a patient’s paralysis, one of the assisting surgeons immediately blew the whistle and called security to escort the criminal surgeon from the room and then did his best to try to repair the damage to the patient,” Holub says. “Unfortunately, there was a history of that particular surgeon being observed to be under the influence of drugs.”
Holub wonders if the surgeon who removed the liver was under the influence of drugs at the time of the procedure and whether the surgeon had been observed by others to be under the influence at other times. It is possible that the hospital should have pulled the plug on the surgeon well before this particular event occurred, he says.
Never events, such as wrong-site surgery, are very rare, says Joe Kopfler, JD, partner with Kopfler & Hermann in Houma, LA. However, when never events do occur, they are devastating to patients, often fatal, and may indicate a fundamental safety problem within an organization. He notes that The Joint Commission has recommended that hospitals report sentinel events and mandates the performance of a root cause analysis after such an event, and Centers for Medicare & Medicaid Services no longer pay for additional costs associated with many preventable events, such as wrong-site surgery.
“In the operating room, the surgeon serves as the captain of the ship. In a non-safety environment, the scrub team and assisting nurses may be too timid to speak out. ‘Stop work’ authority, often used as a safety measure in industry, should be implemented in the operating room,” Kopfler says. “The entire surgical team should know their mission: to perform the specific surgery on the specific patient.”
The hospital where the liver removal occurred apparently lacked a training program for these basic safety procedures, Kopfler says. A thorough investigation must take place focusing on the surgeon and the root cause of the error, especially because physicians are not immune to issues like substance abuse, he says.
“Often, hospitals have policies and safety procedures, but that alone does not protect patients. It is important for hospitals to adhere to these policies to maintain a safe environment that puts patient safety first,” he says. “As with any root cause analysis, lessons learned must be communicated to all personnel at the facility for education and to ensure the harm does not recur.”
Sources
- David W. Holub, JD, Merrillville, IN. Telephone: (219) 736-9700.
- Joe Kopfler, JD, Partner, Kopfler & Hermann, Houma, LA. Telephone: (985) 509-8028.
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.
The surgeon whose license was suspended in Florida for a shocking medical error has had his license suspended in Alabama for that and other incidents.
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