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How Wrong Site Surgery Affects Patients and How It Can Be Avoided


Date Posted: 10/2/2020 3:15:34 AM

Posted By: Ara Akinyi  Membership Level: Silver  Total Points: 187


Wrong site surgery is growing in prevalence over time. It claims gross medical harm to victims and sometimes resulting in death. Few victims and clinicians report medical mistakes thus diagnosis at later stages may lead to gross impacts. The impacts of sentinel events do not only harm the victim but also the perpetrators psychologically. However, there are institutions and procedures, which have been set up to minimize the occurrence of wrong site surgeries. The study focuses on veterans as the victims while veteran hospitals and other private healthcare providers are the perpetrators. The study explains sentinel events through two cases Benjamin Houghton v. VA and Yeary v. VA. It also explains how to make claims and why it is hard for victims to win wrong site surgery cases. The paper also provides remedies available for the victims.


Surgery is a risky course with which minimal errors are expected. However, humans are susceptible to error therefore, preventable mistakes occur during procedures, often referred to as wrong site surgery. Wrong site surgery includes operating on a different member of the body, different procedures on the body, on the wrong patient, and injurious procedures, which cause more than minimal harm to the patient. Wrong site surgeries also include using prosthesis apparatus on a different organ or in the wrong way. Wrong site surgery causes occur in two aspects, systems and process. Systemic causes of wrong site surgeries include lack of supervision to verify the right body member for operation, surgeons acting independently without teams, lack of full information, emergencies, and rush at pre-procedure tasks, inadequate staff, practitioner incompetence, and prevailing condition of the patient. Procedural factors that increase the chances of wrong site surgeries include, insufficient information regarding the prevailing condition of the patient, misinformation, various opinions at the operation room, failure to comply

with the stated procedures, and lack of prior preparation. Wrong site surgery is becoming a culture as complacent healthcare providers accept such injuries as part of human errors, which cannot be avoided while critical others view it as unacceptable conduct and punishable. Responsibility among patients and operation teams is therefore key in ensuring due diligence is performed and protocols followed to the latter to reduce harm.

The Joint Commission Board of Commissioners recognized wrong site surgery frequency and formulated the universal protocol for wrong site surgeries in 2004 to prevent medical errors and mistakes. The main objective of a medical practitioners’ regulatory board is to enhance accountability among medical staff through the universal protocol. The protocol involves procedures before surgery, marking the site for operation, and timeout processes. The preoperative verification procedure identifies critical information that might be missing or incorrect details, verifies the patient, and the correct site for operation. The second stage involves the operating medic marking the body member of the patient to be operated. The timeout process occurs just before the incision begins where the team verifies all the patient, procedures, details, and documents. The guidelines stressed the contribution of operating teams to avoiding wrong site surgeries since the protocol demands that all members of the team be aware of the procedures. The protocol also works to avoid over-reliance on human memory since human memory is dynamic and prone to forgetfulness. Besides, when marking sites for surgery, it is important to involve the patient while making use of all senses, physical, mental, and emotional skills to notice underlying complications and unusual features. The board urges all stakeholders to communicate actively in case they fear the actions of clinicians endanger the life of the patient. However, the set of protocols cannot protect the patient from incompetent clinicians and carelessness during the surgery. The guidelines provide only what should be done before the error occurs but not actions to take in case of occurrence.

Causes and consequences:

Wrong site surgery can be detrimental to patients as well as medical practitioners. The Joint Commission Board applies punitive measures against surgeons who conduct wrong site surgeries or leave foreign objects in bodies of patients. Patients, however, can press charges and seek malpractice claims. According to Mulloy and Hughes (2008), 79 percent of victims who suffered wrong eye surgery, and 84 percent who had orthopedic cases were compensated (Hughes & Mulloy, 2008). Some insurance companies also stopped paying health centers in cases of wrong site surgery.

Before 2000, health practitioners could not establish a definite number of cases of wrong site surgery since there were no clear procedures for monitoring, identifying, and reporting incidents. The reporting systems before the year 2000 have been criticized as inaccurate hence unreliable. According to Peggy Edwards (2008), sentinel events occur every 5-to10 years or one in 112994 cases (Edwards, 2008). However, Cobb (2012) suggests that wrong site surgeries occur 40 times in a week (Cobb, 2012). Medical facilities impose harsh punishment on practitioners who perform wrong site surgery. The occurrence of wrong site surgery is less prevalent. However, reports are even fewer especially among medical practitioners due to the fear of punishment, which further corrupts their integrity. The results of wrong site surgeries are always detrimental to clinicians due to personal conscience and legal actions. Effects that wrong site surgery causes to clinicians include psychological manipulations such as perceived error, guilt, self-doubt, fear and depression, suicide, and loss of confidence in duty. Surgery requires ultimate precision and caution, failure to which inflicts bodily injury on patients, and betrays the trust between patient and practitioner.

Benjamin Houghton vs VA:

Benjamin was serving in the air force when he discovered he had metastatic testicular cancer on his left testicle in 1989. In 2006, Houghton visited a health center wherein the physician suspected the existence of cancerous cells and recommended excision of the left testicle to do away with the risk of illness. Houghton attended an operation in June 2006 to remove his left testicle suspected to have cancer cells. The hospital assigned John T. Leppert a fifth-year medical student to attend to Mr. Houghton's procedure. The procedure included a vasectomy on the right testicle and removing the left testicle. During the procedure, the operating team mistakenly removed the healthy right and performed the vasectomy on the sick left testicle (Engel, 2007). The event is a wrong site surgery since the procedure occurred on a different part of the body other than the recommended organ.
Houghton, in his proposition, trusted the judgment of the medics at VA Hospital. He relied on the view of the top VA officials that the institution was "a benchmark by healthcare organization throughout the world," and hoped to get highly safe services (Engel, 2007). The error resulted in critical consequences including physiological complications. Houghton lost testosterone that further caused fatigue, emotional instability, weight gain, sexual dysfunction, and osteoporosis, which is an incurable bone disease. Houghton sued VA hospital and its surgeon for the injury acquired. The court validated the damage and established that several systemic and procedural errors occurred leading to the injury of the plaintiff. Houghton won the suit and compensation amounting to 200000 US dollars in 2013 (Engel, 2007).

Concerning Houghton’s accident, the event emphasizes the importance of communication, consultation, and proper systems. The court established that it was not certain whether the targeted testicle was cancerous; however, the Houghton attested that it was painful and unhealthy. Clinicians should consult and seek guidance when they are not sure about a procedure. Consulting fellow medics widens individual perspective, inspires new ideas ensures maximum success, and limits possible errors. According to Elizabeth Gam, doctor and patient should establish open communication with their teams and patients. (Gam, 2018). Doctors, however, should be keen to notice the effects of diagnosis on the patient. Doctors should also be honest enough to admit their mistakes. The clinician failed to mark the surgery site, which is a crucial step in the preoperative procedure. The clinician also had no documentation for the preoperative procedure except for a consent form, which the patient and the clinician signed. The patient, however, could not read without his glasses on therefore he just signed oblivious of what the consent was (Engel, 2007). It is mandatory, however, that the patient has to get a full understanding of the consent by reading personally before signing. Subsequent actions such as surgery should rely on the diagnosis report as it defines the actual problem. Every action within the operation room should synchronize directly with the solution of the specific problem as defined by the diagnosis report. Operating teams must also ensure the process accurately follows the standard procedure for the problem. An incident of wrong site surgery always links up to several minor mistakes therefore the focus widens beyond the practitioner to related possible mistakes. VA Hospital has however restructured its operations.

Tony Yeary vs VA:

Disabilities sometimes arise from wrong site surgeries. Mr. Yeary sued VA for medical battery and claims indefinite compensation for injuries sustained in May 2012. In Mr. Yeary's lawsuit, a resident doctor who attended to him used little anesthesia and applied “brute force” while trying to insert a scope into the penis of the plaintiff. After the procedure, with the help of another medic, the clinician left him “splattered in urine and blood” and in “excruciating pain” to “fend for himself” (Swiatek, 2014). The hospital later released him from the facility without pain-relieving drugs. The plaintiff returned to the facility to seek treatment for the blockage of the urinary tract. During the visit, he categorically said he did not want the previous medic attending to him (Swiatek, 2014). However, he realized later that the same clinician had attended to him and allegedly stabbed his rectum and prostrate in the operation. The error caused a permanent scar and damaged, thus he suffered and underwent urinary problems. Mr. Yeary’s new physician later recommended an appendicovesicostomy, a procedure involving setting up an alternative system to pass the urine through the stomach.

Service members who obtain disabilities because of sentinel events have remedies for their injuries. Service members seek a legal claim from the Department of Veteran Affairs or through federal tort (Free Torts Claims Act (FTCA). In the case of disability, compensation to veterans is termed as Section 1151 (Wadsworth, n.d.). When the patient has disabilities and treatment for a condition makes it worse, the victim only requests for more compensation. On application, the plaintiff must prove error in judgment, negligence, incompetence, carelessness, or any other reasonable cause (Wadsworth, n.d.). To prove cases against the VA may be hard, therefore, in addition to circumstances, the veteran plaintiff needs to have an independent medical officer to prove their injury (Wadsworth, n.d.). Such cases are difficult to win especially for persons who suffer more despite their disability, as it is difficult to prove the increased impacts of disability. The victim must also prove that reasonable care would have changed the situation. The system, however, makes it easier for victims of sentinel events to apply for claims (Wadsworth, n.d.).

Wrong-site surgery is a devastating procedure in which, instead of causing relief to the patient, it harms them more. The law entitles veterans compensation through the Veterans Act provided they prove their cases. The threshold for a valid case is negligence, incompetence, and error in judgment, carelessness, or any other reasonable agreement. The Joint Commission Board provides a protocol, which could reduce the occurrences by enhancing preparedness. Despite working to reduce the incidences, wrong site surgeries are unacceptable and should not happen. The protocols alone may not do away with the errors completely human dynamics to dynamics especially after incision. Patient involvement is also important in avoiding sentinel events. The goal of every medical practitioner should be to do away completely with the wrong site surgeries.

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