Surgical Errors Leave Devastating Impact On Families

Surgeries and hospital stays are designed to improve a patient’s health. When patients are harmed by a preventable medical error, they can feel robbed of that natural expectation of help and healing.

The recent operation on the wrong side of a St. Ann woman’s brain at SSM St. Clare Health Center has renewed the sense of betrayal and disbelief among other victims of medical errors.

“These errors really cast a very, very long shadow,” said Martha Deed, whose daughter, Millie Niss, 36, died in 2009 after contracting several infections during a stay at a hospital in Buffalo, N.Y. “What was supposed to be a safe place turned out to be a very dangerous place.” An autopsy report showed Niss had a spinal infection that doctors told Deed was treatable. The New York state health department cited the hospital for two nursing errors related to Niss’ care. “Three months into dealing with losing my daughter I suddenly discovered I needn’t have lost her,” Deed said. “It is so catastrophic that you basically can’t get your head around it.”

Investigations of medical mistakes nearly always point to a breakdown in communication among hospital staff. The potential for mistakes is highest when routines are delayed or changed. Operating rooms are turned over quickly, nurses change shifts in the middle of a procedure and doctors fail to lead pre-surgery checklists.

In a rare public admission, Dr. David Ring of Massachusetts General Hospital wrote in the New England Journal of Medicine in 2010 about a wrong surgery he performed on the hand of a woman, 65. Stress ran high in the hospital that day because several surgeons were behind schedule. The woman’s surgery was moved to another operating room. Marks on her hand were inadvertently washed off with an alcohol solution. Without finishing the required pre-surgery time-out, Ring performed a carpal-tunnel instead of a trigger-finger release. He realized the mistake 15 minutes later while writing the post-operative report, apologized to the patient and performed the correct surgery the same day. “I hope that none of you ever have to go through what my patient and I went through,” Ring wrote in a presentation to hospital staff. “I no longer see these protocols as a burden. That is the lesson.”

Dr. Julia Hallisy founded the Empowered Patient Coalition after her daughter Kate, 10, died while fighting cancer and an infection she contracted during a biopsy in a hospital in San Francisco. “Even as a highly educated health care provider myself, I was struggling at the bedside to understand what was going on, to know the right questions to ask,” said Hallisy, a practicing dentist. “It really became clear to me that when the time was right in my life, I needed to work on helping patients and their families evaluate what they’re seeing to know if they’re seeing a glitch in safety.” Patients and caregivers have told Hallisy they are intimidated by doctors and nurses and feel too scared to speak up or ask questions. The coalition provides worksheets and checklists for patients and families to use during their medical care. “When you’re communicating with doctors and it’s respectful, concise and organized, they’re going to appreciate that,” Hallisy said. “Health care providers absolutely know that you need to turn a bedridden patient every two hours. They know they need to wash their hands. I tell people all the time, you are not asking for something unreasonable, something every health care provider would not want for their own family.”

Every year thousands of patients fall victim to surgical error. A surgical error is a form of medical malpractice and is considered a preventable mistake that occurs during surgery. An Institute of Medicine study shows that medical error is the cause of an estimated 98,000 deaths per year. There are many different surgical errors that can occur during an operation.

U.S. hospitals reported that the following surgical errors are the most common:

1) The wrong patient is operated on

In this instance, a doctor may conduct a surgery on the wrong person. Although hospitals and surgery centers are required to have a patient verification system in place, this system is not fool-proof and is not always followed by the healthcare providers. This not only delays the correct patient’s surgery but also can cause dangerous side effects to the patient who received the wrong surgery.

2) Surgical equipment is left inside a patient

After conducting a long surgery, medical staff or surgeons may accidentally leave operating tools inside of the patient. Depending on the foreign material let in the patient, this can have deadly consequences. At a minimum, a patient will likely need a second, unnecessary operation to remove the foreign material. This additional surgery unnecessarily subjects the patient to the risks of anesthesia and the complications associated with cutting into the body.