As a former hospital administrator, I know that hospitals must have policies and procedures in place to ensure that the correct surgeries are done on the correct body part of the correct patient. Despite accrediting and legal requirements, though, these basic mistakes still occur.
There’s a current story in the news about a shocking mistake so bad that it resulted in criminal charges.
In August 2024, 70-year-old William Bryan felt sudden left-sided abdominal pain and went to the emergency room at Ascension Sacred Heart Emerald Coast Hospital, in Miramar Beach, Florida. He was sent for radiology scans, which suggested a potentially enlarged spleen but no active bleeding.
The staff consulted a general surgeon, Dr. Thomas Shaknovsky, who recommended and urged Mr. Bryan to have a laparoscopic splenectomy. A laparoscopic technique is minimally invasive, rather than a conventional open procedure. A splenectomy is a significant surgical procedure to remove a patient’s spleen, and when done laparoscopically it takes around six weeks to recover.
The surgery was scheduled for three days later. According to Associated Press reporting, instead of removing Mr. Bryan’s spleen, which is on the left side of the body, though, Dr. Shaknovsky removed his liver, on the right side. In the process, the surgeon severed the inferior vena cava, a major vein, causing catastrophic blood loss. Mr. Bryan tragically died on the operating room table.
In September 2024, the Florida Department of Health suspended Dr. Shaknovsky’s medical license in an emergency order, citing the surgery as one of several egregious errors. This reminds me of the Texas Medical Board’s emergency order against Dr. Christopher Duntsch, who’s been dubbed “Dr. Death.” I represented a client who was rendered quadriplegic by Dr. Duntsch’s operating room conduct.
In April 2026, a Walton County, Florida grand jury indicted Dr. Shaknovsky on second-degree manslaughter. He was arrested, released on bond, and faces up to 15 years in prison if convicted. His arraignment is scheduled for May 2026.
The hospital emphasized that Dr. Shaknovsky was never its employee and has not practiced there since the incident. This is similar to the arrangement in Texas, where the corporate practice of medicine doctrine prohibits hospitals from directly employing physicians.
This tragedy isn’t an isolated “oops” moment. It exemplifies wrong-organ or wrong-site surgery, which is one of the most preventable and horrifying medical errors. These cases fall under the broader category of wrong-site, wrong-procedure, and wrong-person events (WSPEs), universally recognized as “never events” by the National Quality Forum and sentinel events by The Joint Commission, America’s largest and oldest accrediting organization for healthcare organizations.
Understanding WSPEs and Their Persistence
Wrong-site surgery occurs when a procedure is performed on the wrong body part, wrong side, wrong level, wrong patient, or involves the wrong procedure entirely. Classic examples include operating on the wrong knee, removing the wrong kidney, or, as here, surgically removing the liver instead of the spleen.
National data show these events remain stubbornly common despite decades of awareness campaigns. The Joint Commission and studies of malpractice claims indicate that WSPEs still occur dozens of times weekly across American operating rooms, with orthopedic, neurosurgical, and abdominal procedures being the most common culprits.
This brings to mind a trial several years ago. When I was questioning the other side’s orthopedic surgery expert witness on the stand, he admitted to amputating the wrong leg of a patient. That’s not much of an expert in my book! We won the trial, by the way.Contributing factors frequently include communication breakdowns, fatigue, incomplete records, failure to review imaging intraoperatively, and skipping or rushing standardized safety checks.
For Dr. Shaknovsky’s case, this wasn’t his first alleged wrong-organ surgery. The Florida suspension order also referenced a prior 2023 incident at the same hospital in which he allegedly removed part of a patient’s pancreas instead of the intended left adrenal gland, later claiming the gland had migrated. That case settled for $400,000.
The Universal Protocol: The Gold Standard for Prevention
In 2004, The Joint Commission responded to an uptick in reports of wrong site/procedure/patient reports by making the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery an accreditation requirement for all in all accredited hospitals, ambulatory surgery centers, and office-based settings.
When I was a hospital administrator, one of my responsibilities was ensuring that our facility complied with The Joint Commission’s requirements. Hospitals take them seriously because they’re tried to accreditation and funding.
The universal protocol rests on three requirements. You may recognize some of these steps as routine from your own hospital experiences.
Pre-procedure verification: Confirm the correct patient, correct site, and correct procedure using multiple sources (consent form, history and physical, imaging, and patient/family input). Discrepancies must be resolved before the patient enters the operating room.
Site marking: The surgeon (or designee) marks the operative site with an unambiguous, indelible marker while the patient is awake and involved when possible. For midline or ambiguous sites, protocols require additional safeguards.
Time-out or surgical pause: Immediately before incision or start of the procedure, the entire team, including the surgeon, anesthesiologist or certified registered nurse anesthetist (CRNA), nurses, and techs, stops all activity. They verbally confirm patient identity, site/side, procedure, positioning, availability of implants/instruments, and any anticipated concerns. No one resumes activity until all questions are answered.
The Universal Protocol is not optional. It defines the standard of care for invasive procedures nationwide. Failure to perform a proper time-out or to reconcile obvious discrepancies constitutes a clear deviation. Courts and expert witnesses routinely cite non-adherence as evidence of medical negligence. It’s hard to imagine how Dr. Shaknovsky could have operated on Mr. Bryan’s wrong side and location if the Universal Protocol had been followed.
The Standard of Care and Medical Malpractice Liability
The standard of care for surgery is what a reasonably prudent surgeon of similar training and experience would do in the same or similar circumstances. That standard now expressly incorporates the Universal Protocol, the World Health Organization Surgical Safety Checklist, and institutional policies mirroring them.
Expert testimony will almost always establish that no competent surgeon, following protocol, confuses a liver for a spleen during a planned laparoscopic splenectomy. Imaging, anatomy, and the time-out exist precisely to prevent such catastrophic misidentification. Based on the Universal Protocol requirements, other members of the operating room staff have an obligation to pay attention and speak up to avoid these preventable and sometimes life-threatening errors.
Legal Consequences
As a former hospital administrator and now Texas medical malpractice attorney for over a quarter of a century, I see these cases as both tragic and instructive. Every operating room in Texas, whether in Houston, Dallas, or a rural hospital, must follow the Universal Protocol for every surgery.
Hospitals that treat the protocol as a checkbox rather than a culture will pay the price both in human lives and in being held accountable in court. The Bryan case should serve as a wake-up call. A man sought help for left-sided pain and died because the wrong organ on the opposite side was removed.
The Universal Protocol exists to prevent precisely this outcome. When it’s ignored or glossed over, it breaches the standard of care and patients and their families are left to seek justice in court.
If you or someone you care for has been injured or has passed away because of a wrong person, wrong site, or wrong procedure in the operating room, then contact a Texas medical malpractice lawyer to discuss legal options about your potential case.
