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Surgeon operates on wrong patient at Houston-area hospital

Operating room nurse notices mistake, tells surgeon, but procedure goes forward anyway

I recently visited with a new client who was taken to surgery at a Houston-area hospital by mistake and is now living with the consequences.

This elderly lady had been hospitalized for an abdominal surgery that had gone well. In fact, her healthcare providers had already planned had for her discharge home in a few days. Still yet, the patient was still a bit groggy from pain medications.

She remembers being rolled out of her room. The next thing she recalls is having a terrible pain on her abdominal area and realizing that she had been taken to surgery without her knowledge or consent.

An investigation revealed that the healthcare providers had taken the wrong patient from her room and taken her to the operating room for surgery. An operating room nurse noticed that it was the wrong patient and raised the issue to the surgeon. The cavalier surgeon brushed her off and insisted on proceeding. The nurse apparently felt bullied and allowed the surgery to go forward.

Prior to this improper surgery, the patient had a small wound on her abdomen that was healing. During this unnecessary trip to the operating room, without her consent, the surgeon debrided and scraped the wound, making it about three times its original size. The surgeon and nursing staff of the hospital put this lady through agonizing pain and an extended healing process that could have been entirely avoided.

As a Houston, Texas medical malpractice attorney, I was very surprised to hear that this happened in 2017 America. Ten or 20 years ago, wrong-patient, wrong-site surgeries were more common. Then, the hospital accrediting organization, The Joint Commission, made the surgical time-out process a national patient safety goal and a universal protocol.

The Joint Commission continues to run what it calls a “Speak Up” campaign about the importance to safety of the surgical time-out. The parameters are pretty simple, but at the same time comprehensive.

The pre-procedure or operation verification process involves healthcare providers verifying the correct procedure for the correct patient at the correct site. Whenever possible, doctors and nurses should involve the patient in the verification process. In other words, ask patients for their name and birthdate, as well as why they are in the operating room.

Even the first part of the surgical time-out process would have spared my new client the pain and suffering of going through an unnecessary surgery. After all, both the patient and her family were unaware of any surgery being scheduled. Instead, they were ready for her to be discharged from the hospital in a few days.

The next step in the surgical time-out process is to mark the procedure site. For example, in the knee surgery, this would involve marking the correct knee. I once cross-examined an orthopedic surgeon at trial who had amputated the wrong leg before the surgical time-out procedures were implemented.

The last part of the surgical time-out process is to perform an actual time-out before starting the operation or procedure. Medical and nursing experts contend that the standard of care requires all members of the healthcare team to be present for this brief moment or two before getting started with the procedure or operation. This includes the surgeon, anesthesia provider (anesthesiologist or certified registered nurse anesthetist/CRNA), operating room technicians, and others. The standard of care requires all healthcare providers to agree, at a minimum, that they have the correct patient, understand the correct operative site, and no what procedure is to be done.

While the operating room nurse realized that there was a problem and spoke up, she was still negligent by not going up the chain of command to stop a surgery on the wrong patient. Under the standard of care and Texas Board of Nursing rules, nurses have an independent duty to advocate for the safety and quality care of their patients.

The operating room nurse should have advocated more forcefully to stop the surgery and to get in touch with a charge nurse or other supervisor before the surgeon and other healthcare provider started the operation. While it is really surprising and disappointing that the surgeon would ignore the warning of a registered nurse, I am confident if she had gone a bit further that this whole predicament would’ve been avoided.

We are here to help

If you or someone you care for has been seriously injured as a result of medical malpractice at a hospital, intermediate care facility, nursing home, or rehabilitation hospital, call the experienced medical malpractice lawyers at Painter Law Firm, in Houston, Texas, for free consultation about your potential case. Our phone number is 281-580-8800.


Robert Painter is an attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who focuses his law practice on medical malpractice and wrongful death cases. He frequently speaks and writes on topics related to healthcare and medical negligence. He is a former editor-in-chief of The Houston Lawyer magazine, and currently serves on the editorial board of the Texas Bar Journal.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.

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