US Man Dies After Wrong Organ Removal – Surge in Surgical Errors Raises Alarm

A 70-year-old Alabama man recently passed away in a Florida hospital after a surgeon mistakenly removed his liver instead of his spleen.

Such errors, known as “never events” because they should never occur, are unfortunately more common than they should be.

Never events include operating on the wrong organ or side of the body, inserting the wrong prosthesis (like hip joints), or leaving foreign objects, such as surgical tools or swabs, inside the patient.

In the UK, provisional NHS data shows that between April 2023 and March 2024, there were 370 never events. In the previous three years, the numbers were 384 (2022-23), 407 (2021-22), and 364 (2020-21). This means approximately one of these incidents occurs daily. While this is a low rate considering the number of procedures performed by the NHS, it offers little comfort to those impacted by these serious errors.

Surge in US Never Events

In the US, the number of never events has recently increased, with 1,440 recorded in 2022 and 1,411 in 2023, compared to fewer than 1,000 in prior years. 2023, 18 percent of these incidents resulted in death, and 8 percent led to permanent harm or loss of function.

In the Alabama man’s case, it’s difficult to see how a surgeon could confuse the spleen with the liver, given that basic anatomy is taught early in medical education.

Afterward, years of postgraduate training further specialize doctors in fields like general surgery, orthopedics, or neurology, reinforcing their expertise. In the UK, surgical careers typically require at least 15 years of training, with similar timelines in the US and other countries. Yet, surgical errors are often the result of multiple factors.

Common Surgical Errors

The most common mistakes involve operating on the wrong side of the body. Humans have pairs of many organs, making left-right confusion a risk. Studies in urology have shown that over 10 percent of clinical letters either fail to specify the diseased side (8.7 percent) or mention the wrong side (3.3 percent). Sometimes, incorrect radiology images cause surgeons to remove a healthy kidney instead of the diseased one.

Other paired structures, like testicles, are sometimes removed from the wrong side, potentially causing infertility. Similar errors have affected women’s fertility, with cases of surgeons mistakenly removing the wrong fallopian tube or healthy ovaries. In one instance, a pregnant woman’s ovary was removed instead of her appendix, resulting in her death.

A US study found that the highest rate of wrong-site surgery occurs in orthopedics (35 percent), followed by neurosurgery (22 percent) and urology (9 percent). Orthopedics often ranks as a high-risk specialty for these errors, with 21 percent of hand surgeons admitting to operating on the wrong site.

Fatal Errors Due to Mistaken Identity and Clerical Mistakes

Occasionally, errors like mistaken identity or clerical mistakes lead to fatalities. For instance, a hospital in the Bronx, New York, accidentally turned off the life support of the wrong patient. In another heartbreaking case, a 17-year-old girl received a heart and lung transplant with organs that were incompatible with her blood type, resulting in her death.

These incidents are rarely detailed in medical journals, likely due to legal concerns. As a result, the media is often the first to report them, though these reports typically lack enough medical detail to help prevent future occurrences.

Never events have serious consequences for patients and their families, often leading to large financial settlements. From 2015 to 2020, the NHS paid out over £17 million in settled claims related to these events, while globally, claims between 1990 and 2010 exceeded US$1.3 billion (£990 million).

Efforts to eliminate never events are ongoing. In 2008, the World Health Organization (WHO) introduced the surgical safety checklist, which the NHS adopted in 2009.

Similar procedures have been in place in the US since 2004.

These protocols standardize care across healthcare providers, and shortly after implementing the WHO checklist, it reduced post-operative complications and deaths by 36 percent. Despite this progress, the occurrence of never events highlights the need for further improvement.

As healthcare demand rises, systems must evolve to maintain patient safety. Since many issues stem from human factors, ensuring adequate staffing, manageable workloads, and staff well-being will be crucial.

Read the original article on: Science Alert

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