Do completely preventable deaths from medical mistakes happen? You bet.

In this day and age of advanced medicine, we expect that medical care meets reasonable standards.  Nobody would envision that after entrusting their health to a hospital and physician that instead of being helped they would be killed.  Unnecessarily.

That’s exactly what happened to William Bryan just two months ago right here in Florida.  Mr. Bryan, visiting from Alabama, started having pain in his abdomen.  After being seen at Ascension Sacred Heart Emerald Coast Hospital in Miramar Beach, FL, the surgeon and chief medical officer recommended that he have his spleen removed.  Instead of taking out Mr. Bryan’s spleen, surgeon Thomas Shaknovsky instead removed the patient’s liver, and in so doing cut critical vessels, causing massive blood loss and Mr. Bryan’s death on the operating table.

The surgeon then removed the liver and labeled it “spleen.”  But it wasn’t his spleen. It was Mr. Bryan’s liver.

This is one example of many where health care providers have failed their patients.  This is known as a “never event” because mistakes like this, much like wrong site surgery itself, are never supposed to happen.  This is not the dark ages of medicine.  Doctors, nurses and health care providers are trained, licensed and certified.   Yet mistakes like this continue to happen.  And they cost lives.

Between 250,000 and 440,000 people are killed by medical mistakes in the United States, making it the country’s third leading cause of death.

Incredibly, it appears that the surgeon who killed Mr. Bryan had already made the same mistake before.  According to his attorney, this is the second wrong site surgery by Dr. Thomas Shaknovsky in two years, with another one at the same hospital being settled in 2023.

A number of procedures have been put into effect in the past few decades to prevent wrong site surgery, but the incidence has not substantially decreased.  Part of this is because wrong site surgery is often never reported to authorities. It may be as few as 10% of these mistakes are ever reported.

Even the rich and famous are not immune from these huge mistakes.  Comedian and actor Dana Carvey’s career and life were derailed when a surgeon operated on the wrong artery during a cardiac procedure, resulting in long term medical problems and a lawsuit that was eventually settled.

The most unbelievable part of wrong site/wrong patient surgery is that many times the doctor committing the mistake has already made the same error…something that should never happen even once.  These repeat offenders do not lose their license, and are rarely if ever publicly humiliated.  Instead, they pay a small fine and perhaps give a lecture or write an article about wrong site surgery.

To really address this problem there needs to be a comprehensive review of ways to prevent these “never events” from happening.  In 1998, American Academy of Orthopedic Surgeons (AAOS) created a “Sign Your Site” program that encourages surgeons to mark their initials on the correct site as part of their pre-operative routine in order to reduce errors. This, combined with a pre-operative “time out” to confirm the correct identity of the patient, procedure to be performed, and location of the surgery, should in theory reduce wrong site mistakes.  But the number of these absurd errors has continued to increase each year.

This means that patients need to be vigilant in their own care. Bring a relative or close friend to the hospital to act as your patient advocate.  Confirm with all care givers the procedure and location before going under anesthesia.  Mark “NO” on the non-surgical limb.  Because leaving it up to the health care providers may mean a surgery in the wrong place.  And nobody heals from that.