Doctors struggle with persistent error: cutting the wrong part

A 58-year-old woman went to a surgery center to have her left knee repaired. She signed a consent form and the doctor verified twice that she had come for surgery on her left knee.

That's not the procedure he performed.

The Brooksville orthopedic surgeon, Fady Zeidan, operated on the woman's right knee.

The state fined Zeidan $5,000 for the April 2008 error. The report doesn't identify the patient. And it doesn't explain how the mistake happened. But Zeidan said he followed every safety procedure, including marking the knee intended for surgery.

"It was a human error. It happens," he said, declining to go into more detail.

Since 2003, the state Board of Medicine has disciplined 42 doctors in the Bay area for committing human errors - cutting on, anesthetizing, probing or irradiating the wrong body part or the wrong patient.

Statewide during the same six years, medical centers reported 280 of these so-called wrong-site and wrong-patient procedures, according to the state Agency for Healthcare Administration.

State Board of Medicine officials downplay the problem. They say no patients have died or been seriously injured during the procedures and the rate is minimal compared with the millions of surgeries performed every year.

But the problem has defied efforts to reduce the numbers. More mistakes are happening now than in 2005, when the board acknowledged its frustration that safety procedures and fines of up to $20,000 hadn't curbed the problem.

The board is "concerned that physicians simply aren't getting the message," spokeswoman Lindsay Hodges said then, referring to the 40 doctors disciplined for wrong-site procedures in 2004.

Four years later, in 2008, the health care agency reported 54 wrong-site episodes.

Doctors in these recent cases won't know whether they will be disciplined until Board of Medicine inquiries are complete.

Valrico internist Fred Bearison, chairman of the Board of Medicine, said the total number of surgeries also has risen.

Still, Bearison finds the growing number of mistakes troubling.

"We see these cases all the time," he said.

Added Eulinda Smith, spokeswoman for the state Department of Health: "Although this type of medical error represents a very small part of the total number of surgical procedures ... it is an error that can be prevented."

Medical researchers confirm wrong-site operations are rare, but say they can be devastating. The mistakes often require a second surgery.

What's more, they can signal more serious safety problems, according to the authors of a 2007 article in the Journal of the College of Surgeons.

Botched procedures

Many of the wrong-site cases in which doctors were disciplined in the seven Bay-area counties were minor.

In a couple, doctors recognized before doing cataract operations that they had put the wrong eyes to sleep. No patients died because of the mistakes. The more recent records show nothing as extreme as in 1995, when Dr. Rolando R. Sanchez, operating on patient Willie King in Tampa, amputated the wrong foot.

But many were serious. Here are some examples from the state's list of disciplinary action against doctors:

Drilling wrong hole. In June 2006, a neurological surgeon at Lakeland Regional Medical Center, Rajan Raj, drilled into the right side of a 77-year-old man's head to relieve swelling in his brain, but the swelling was on the other side. After making the hole, the doctor realized the problem and switched. He didn't record his mistake in the surgical record. He was fined $10,000.

Missed vertebra. In March 2007, a doctor at Regional Medical Center Bayonet Point, Wayne Wittenberg, operated on a 73-year-old woman to remove a benign tumor on her spine in the mid-back. But he had miscounted while trying to mark the spot before surgery and opened her up at the wrong vertebra. The patient had to return to surgery the next day to have the tumor removed. He was fined $7,500.

Wrong heart patient. In May 2008 at Tampa General Hospital, a doctor performed a heart catheterization on the wrong patient. The patient was supposed to have a procedure that involved swallowing a small tube with a heart monitor. In a catheterization, a tube is inserted through an artery or vein and moved toward the heart to measure its function. The doctor, John Sullebarger, was fined $12,500 for failing to verify the patient's identity.

Swapped lenses. In April 2006, at Brandon Ambulatory Surgery Center, a doctor, Craig Berger, implanted the wrong artificial lenses into the eyes of two patients undergoing cataract surgery. Berger was fined $10,000.

Steps to get it right

Procedures in which doctors got the site or the patient wrong account for nearly 20 percent of the cases in which doctors have been disciplined in the Bay area since 2003 - 42 out of 235.

They arise from complaints filed with the Department of Health. The Board of Medicine makes the final decision on discipline.

Statewide, about 29,000 complaints have been filed against doctors since 2003. About 1,280 doctors have been fined or reprimanded. The majority of recent cases in the Bay area resulted in nothing more severe than a fine.

Many of the Tampa-area doctors were fined for failing to order tests or take the necessary steps to diagnose a patient's disease. In about 10 cases, according to the state complaints, the doctors had left objects inside patients during surgery. About 20 had incorrectly administered or prescribed drugs.

It's the cases involving the wrong site or wrong patient that frustrate much of the medical community.

Doctors and surgery staffs are supposed to take a half-dozen steps to make sure the body part or patient they are working on is the right one. The steps include verifying the patient's identity, labeling the correct body part with a marker, if possible, then pausing before the procedure to double-check name, procedure and positioning.

In many local cases, doctors took precautions but still made mistakes.

The state's report on the knee surgery case in Brooksville said Zeidan verified twice before surgery that he was supposed to operate on the patient's left knee. Zeidan said the knee was marked.

"I took every precaution," he said.

But some cases show lapses at several levels, including with the patient.

In the case of the wrong catheterization at Tampa General last year, the patient, a man identified as L.B., was rolled into the procedure room with another patient's medical chart.

"The transporter did not read L.B.'s identification bracelet," the state report said.

When asked, the man mistakenly confirmed to a lab technician that he was the other patient, identified in the report as D.O. The man spoke Spanish; so did the technician. Before beginning the heart procedure, Sullebarger didn't check the patient's armband to verify his identity.

As Sullebarger was performing the procedure, it became clear he had the wrong patient so he immediately stopped, the state report said.

The fine in this case, $12,500, was one of the highest among Bay-area cases, though regulators can go as high as $20,000.

The Brandon eye case seems to be the result of a scheduling problem, the state report shows. One of the patients arrived late, so the doctor's staff changed operating times, but the doctor didn't verify the names.

Both were having cataracts removed and artificial lenses implanted. Both received the wrong lenses and had to return to surgery for corrections.

Eye, orthopedic procedures

In a three-year look at wrong-site surgery cases, Board of Medicine member John Beebe of Pompano Beach determined the overall problem was minimal. Between 2006-08, the board reviewed 141 wrong-site cases out of some 12.7 million procedures - a rate of about 1 in 100,000.

This is "but a fraction of the defect rate experienced by the world's leading manufacturers," Beebe wrote.

He singled out eye and orthopedic doctors, though, as groups that could reduce their numbers. These doctors, he said, are more likely than others to operate on the wrong body part or use the wrong procedure.

Bringing their rate of mistakes in line with all other specialties would cut the number of wrong-site surgeries each year by 18 percent, from 45 to 37, Beebe said.

Still, Beebe insisted the overall danger has been less than Floridians think.

"While the potential for patient harm is ever-present when WSS (wrong-site surgery) occurs, actual patient harm was minimal with the exception of wrong-sided burr holes," he wrote. "No wrong side limbs were amputated. No wrong side organs were removed or replaced."

That assessment proved premature, however.

Beebe presented his paper to the Board of Medicine at its June meeting. At the same meeting, members discussed a wrong-site case from South Florida.

A Harvard-trained doctor in Broward County, Bernard Zaragoza, mistakenly removed a man's kidney instead of his gallbladder during a laparoscopic procedure. The doctor was fooled by scar tissue in the abdominal cavity, according to a Health News Florida report.

Department of Health prosecutors and the doctor settled on a $5,000 fine, but the board decided Zaragoza should be fined $10,000.

Like all doctors disciplined by the board in these cases, he will also have to give a lecture to other doctors - on how to ensure they are operating on the right patient and the right body part.

FILING A COMPLAINT

Florida has a process for filing complaints against any health care practitioner or center that is regulated by the Department of Health's Division of Medical Quality Assurance.

Contacts

• Click "File a complaint" at www.doh.state.fl.us/mqa

• Or call 1-888-419-3456 or (850) 245-4339 to request a form in the mail.

Time limits

• For incidents before July 1, 2006, there is no time limit, but for incidents after that, you must file within six years.

• If the incident involved fraud, the limit is 12 years.

• There is no limit if the incident involves diversion of controlled substances, sexual misconduct or impairment by a practitioner.