It happened again. A surgical team operated on the wrong knee.
According to a lawsuit, a patient at Christus St. Vincent Regional Medical Center, in Santa Fe, went to the hospital for an arthroscopic surgery on her left knee. The surgeon, anesthesia provider, and operating room (OR) nursing staff did the procedure, provided their care, and transfer the patient from the OR to the recovery room.
Believe it or not, that’s when they first discovered the problem. Someone was probably reviewing the paperwork and figured out that the surgical team made a massive error and operated on the wrong knee. What happened next is that they essentially turned the patient around, wheeled her back into the OR, and did the same operation on her correct knee.
I can’t imagine how shocked and upset the patient and her family were after all this was over. Instead of having to endure pain, recovery, and rehabilitation with one knee, she was involuntarily thrown into the situation of having to deal with two knees at once.
As a former hospital administrator and a long-time Houston, Texas medical malpractice attorney, this type of situation never ceases to amaze me. Accrediting agencies, like The Joint Commission, describe wrong-site surgeries as never events. In fact, accredited hospital and ambulatory surgery center operating rooms all over America follow what’s called the universal protocol.
The universal protocol includes a brief timeout in the operating room before surgery begins. Ideally, the surgeon, anesthesia provider, nurses and even patient participate. The goal is to make sure everyone agrees that they have the right patient for the right procedure in the right place.
When healthcare providers and operating rooms get busy, I have found that they sometimes skip the universal protocol. In many situations, one anesthesiologist is supervising or directing four or five certified registered nurse anesthetists (CRNAs). Some surgeons double and triple book their time, meaning they will be involved in multiple surgeries on different patients at the same time.
It’s understandable that hospitals, surgery centers, and healthcare providers want to be more efficient with their time. But this type of efficiency only goes so far.
I know if I had to go to an OR for a surgery, I’d ask to hold off on starting the anesthesia until the surgical timeout was done. After all, it seems like I hear about this type of never event happening all the time.
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Robert Painter is a 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 against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2018, by H Texas as one of Houston’s top lawyers. Also, in 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.
