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Negligent Security Seminar | March 2015

Florida personal injury lawyers

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    Wrong site surgery? It Happens a Lot. Medical Errors are the Nation’s 3rd Leading Cause of Death.

    Who would expect a doctor to perform wrong site surgery? With today’s advanced medicine, it seems unthinkable.  Think again.

    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 was a variation of the dreaded “wrong site surgery” — this was wrong organ removal!

    This is one example of many where health care providers have failed their patients.  This is known in medicine 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.

    At Leighton Panoff Law, we have seen these “never events” all too often.  This includes one orthopedic surgeon who operated on the wrong leg of our client.  It turned out the same doctor had operated on the wrong leg of another patient just a year earlier.  Yet the mistakes continued.

    This is one reason why a patient advocate is so important in helping prevent these mistakes before they happen.  Because leaving it up to the health care providers may mean a surgery in the wrong place.  And nobody heals from that.

    What is wrong site surgery and how often does it happen?

    Wrong site surgery refers to surgical procedures performed on the wrong part of the body, the wrong patient, or even the wrong organ. While these errors are classified as “never events” — meaning they should never occur — they still happen with alarming frequency. Despite established protocols like surgical site marking and pre-op time-outs, wrong site surgeries continue to be reported, and experts believe that only about 10% of these incidents are ever officially documented.

    How can a surgeon mistake a liver for a spleen during surgery?

    A case reported at Ascension Sacred Heart Emerald Coast Hospital in Florida illustrates how devastating such an error can be. A surgeon was supposed to remove a patient’s spleen but instead took out the liver, causing fatal blood loss. The liver was then mislabeled as the spleen. This type of wrong organ removal is a severe variation of wrong site surgery and reflects critical failures in surgical verification protocols that should prevent such confusion.

    Are wrong site surgeries preventable?

    Yes, wrong site surgeries are entirely preventable and are categorized as “never events” in the medical field. Strategies like the “Sign Your Site” initiative and pre-operative “time outs” were introduced to eliminate these errors. However, these procedures are not always followed effectively, and the problem persists. Enhanced enforcement and accountability, along with patient advocacy, are essential to truly prevent these errors.

    What should patients do to avoid becoming victims of surgical mistakes?

    Patients are encouraged to take an active role in their medical care to reduce the risk of surgical errors. Bring a trusted friend or family member as a patient advocate, clearly confirm the procedure and surgical site with every caregiver, and mark “NO” on the limb or body part that should not be operated on. These proactive steps can help prevent irreversible mistakes like wrong site or wrong organ surgery.

    Why do doctors who commit wrong site surgeries keep their licenses?

    Shockingly, many surgeons who commit wrong site surgeries — even more than once — are not stripped of their medical licenses. Instead, they may face minimal consequences such as fines, mandatory lectures, or authoring articles. These light repercussions mean that repeat offenders remain in practice, often without public accountability, putting future patients at risk.

    Is wrong site surgery often reported to authorities?

    Unfortunately, most wrong site surgeries are never reported to state or federal authorities. It is estimated that as few as 10% of these catastrophic mistakes are officially documented. This lack of transparency hinders efforts to track patterns, enforce standards, and ultimately protect patients from preventable medical harm.

    How can Leighton Panoff Law help victims of wrong site surgery?

    Leighton Panoff Law has extensive experience representing victims of wrong site surgeries and other catastrophic medical errors. The firm understands the devastating impact these “never events” have on individuals and families. Whether it’s a surgeon operating on the wrong leg or removing the wrong organ, Leighton Panoff Law fights to hold negligent parties accountable and secure justice for their clients.

    Article by:

    John Leighton

    A nationally-recognized trial lawyer who handles catastrophic injury and death cases. He manages Leighton Law, P.A. trial lawyers, with offices in Miami and Orlando, Florida. He is President of The National Crime Victim Bar Association, author of the 2-volume textbook,Litigating Premises Security Cases, and past Chairman of the Association of Trial Lawyers of America’s Motor Vehicle, Highway & Premises Liability Section. Having won some of the largest verdicts in Florida history, Mr. Leighton is listed inThe Best Lawyers in America (14 years), “Top Lawyers” in the South Florida Legal Guide (15 years), Top 100 Florida SuperLawyer™ and Florida SuperLawyers (14 years), “Orlando Legal Elite” by Orlando Style magazine, and FloridaTrend magazine “Florida Legal Elite

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