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In healthcare terminology, 'never events' refer to critical mistakes that are entirely preventable and should never occur. Yet, as we will discover, these incidents happen more frequently than medical professionals might acknowledge.
Since 2011, 29 types of incidents have been categorized as never events. These encompass a range of errors, such as patients falling from hospital beds, incorrect treatment methods being applied, surgical tools being left inside patients, and operations being performed on the wrong individuals.
This discussion will concentrate on never events specifically occurring during surgical operations.
10. A 17-Year-Old Receives Incorrect Heart and Lungs in Transplant Surgery
In 2003, Jesica Santillan, a 17-year-old, faced what is considered one of the most tragic never event incidents in medical history. Three years prior, her parents had illegally brought her into the U.S. seeking treatment for her deteriorating heart and lungs. After reading her story in a newspaper, philanthropist Mack Mahoney generously covered her medical expenses for surgery at Duke University Hospital.
On February 7, 2003, Santillan underwent the procedure, but her condition worsened when the surgeons transplanted organs from a donor with an incompatible blood type. The donor had type A blood, while Santillan had type O, leading to severe complications.
Santillan’s body rejected the transplanted organs, causing her to suffer multiple seizures and requiring life support. Two weeks later, she had a second surgery with compatible organs. While the new organs functioned properly, the delay had caused irreversible brain damage, and she remained on life support until it was eventually discontinued.
At the time of her passing, approximately 200 individuals in the U.S. were awaiting heart-lung transplants. Santillan was initially at the bottom of the list but was moved to the front due to the critical nature of her condition.
The medical mistake led to the loss of two sets of organs and diminished the survival prospects for other patients in need of transplants, as it deprived them of these vital resources.
9. An 83-Year-Old Woman Receives Heart Surgery Meant for a Respiratory Infection
Mediclinic Kimberley Hospital in Johannesburg, South Africa, experienced a never event when staff mistakenly performed heart surgery on 83-year-old Rita du Plessis, who was admitted for a respiratory infection. The procedure was intended for a different patient.
Du Plessis and another patient scheduled for heart surgery shared the same doctor. The physician instructed a surgeon to prepare the other patient for the operation, but the surgeon confused the names and operated on du Plessis instead. Her family was later informed that the surgery had been successful.
The staff only became aware of their mistake when the physician, searching for du Plessis, informed them they had operated on the wrong patient. The doctor later contacted du Plessis’s family to clarify the error and offer an apology. The hospital waived all charges for the surgery.
8. Woman Has Breast Removed Due to Misdiagnosed Cancer
In April 2015, Eduvigis Rodriguez, 49, underwent surgery to remove what was believed to be an aggressive cancer in her left breast. After the procedure, post-surgery tests revealed she never had cancer. The lump was actually caused by sclerosing adenosis, a non-cancerous condition involving abnormal tissue growth in the breast.
The incorrect cancer diagnosis originated from a biopsy at Mount Sinai Beth Israel Hospital, which led to her referral for surgery at Lenox Hill Hospital in Manhattan. However, this does not absolve the staff at Lenox Hill of responsibility.
According to hospital protocols, Lenox Hill staff were required to conduct tests to verify the initial diagnosis. However, they failed to do so, despite Dr. Magdi Bebawi, the surgeon, signing documents asserting that the tests had been completed. Following the unnecessary mastectomy, Rodriguez underwent reconstructive breast surgery and experienced complications, including a surgical hernia and a pulmonary embolism, as documented in court records.
7. Incorrect Patient Receives Brain Surgery
In 2018, Kenyatta National Hospital in Kenya gained notoriety when a patient received brain surgery meant for someone else. Both patients were admitted unconscious and placed in the same ward, but their identification tags were swapped, leading to the wrong individual being taken to the operating room.
The intended patient had a brain blood clot, while the other only had head swelling. Surgeons operated on the wrong patient for two hours before realizing their mistake when no blood clot was found.
The hospital administration suspended the neurosurgeon, anesthetist, and two nurses involved in the procedure. Ironically, the patient who was supposed to undergo the surgery no longer required it, as his condition had already begun to improve.
6. Elderly Woman Passes Away After Unnecessary Brain Surgery for Jaw Misalignment
Oakwood Hospital in Michigan faced significant backlash after 81-year-old Bimla Nayyar underwent unnecessary brain surgery. The situation worsened when Nayyar fell into a coma and passed away 60 days later.
Nayyar was admitted to Oakwood Hospital in January 2012 for a jaw displacement, a condition that typically requires straightforward treatment. However, a CT scan mistakenly attributed to her showed brain bleeding, prompting an emergency surgery. The scan, however, belonged to another patient.
During the operation, five holes were drilled into Nayyar’s skull, and the right side was opened. Surgeons only recognized their mistake when no signs of brain bleeding were found. They notified her family of the error but downplayed its seriousness.
Nayyar never woke up after the surgery and remained on life support for 60 days until the ventilator was turned off on March 11, 2012. Her family pursued a lawsuit and was granted $21 million in compensation.
5. Surgeon Removes Wrong Leg During Operation and Unauthorized Toe Amputation
In February 1995, Dr. Rolando R. Sanchez faced severe repercussions after amputating the healthy leg of 52-year-old Willie King instead of the diseased one. A nurse discovered the mistake while reviewing the patient’s file and broke down in tears, alerting Sanchez to the error mid-surgery.
Sanchez refused to accept blame, attributing the mistake to other staff. The operating room’s blackboard, schedule, and hospital computer all incorrectly listed the wrong leg for amputation.
The incorrect leg had been prepped for surgery before the doctor arrived. Sanchez claimed he didn’t realize he was operating on the wrong leg because it also showed signs of disease and might have required removal in the future.
Sanchez’s medical license was suspended in July 1995 following another surgical error. During this incident, he amputated Mildred Shuler’s toe without her consent. Shuler was undergoing surgery to remove infected tissue from her right foot when, according to Sanchez, a diseased bone “popped,” prompting him to remove it to prevent infection.
4. Healthy Patient Loses Healthy Kidney in Unnecessary Surgery
An unnamed patient at St. Vincent Hospital in Worcester, Massachusetts, lost a healthy kidney after doctors confused him with another patient. The intended patient had a CT scan showing a kidney tumor and was scheduled for its removal.
The mix-up was discovered after post-surgery tests confirmed that the removed kidney was healthy.
The hospital staff was held accountable for the incident due to their failure to adhere to proper identification procedures. Although both patients shared the same name, leading to the confusion, their ages differed. Greater attention to detail would have prevented the mistake.
3. Surgeon Removes Incorrect Testicle During Operation
In 2013, Steven Hanes underwent surgery at J.C. Blair Memorial Hospital in Pennsylvania to remove a painful and damaged right testicle. However, the surgeon mistakenly removed the left testicle instead.
Dr. Valley Spencer Long explained that he confused Hanes’s right testicle for the left one, claiming the testicles had shifted positions. Hanes sued the surgeon and the hospital, receiving an award of $870,000.
2. Surgeon Removes Woman’s Reproductive Organs Instead of Appendix
In March 2015, an unnamed woman in the UK visited a hospital under the Sheffield Teaching Hospitals Trust, reporting abdominal pain. Tests confirmed appendicitis, and she was scheduled for an appendectomy.
However, the surgeon mistakenly removed an ovary and fallopian tube. The doctor dismissed the error as minor, attributing it to poor vision and the similar appearance of the appendix and fallopian tube.
UK medical authorities disagreed. This was the surgeon’s third surgical error in two years. In September 2013, he had mistakenly removed fat from a patient who required an appendectomy, leaving the patient in severe pain until corrective surgery was performed a month later.
In another case, the surgeon removed a skin tag instead of a cyst. Although the doctor apologized for the errors, he was prohibited from treating additional patients.
1. Healthy Newborn Boy Accidentally Receives Frenulectomy
The University Medical Center in Lebanon, Tennessee, faced scrutiny after a one-day-old infant named Nate underwent an unnecessary tongue-clipping surgery (frenulectomy). This procedure involves removing the tissue that connects the tongue to the mouth’s floor.
A surgeon had requested baby Nate, and a nurse took him from his mother, Jennifer Melton, without explanation. Jennifer assumed it was a routine postnatal checkup. She only discovered the surgery when the nurse began explaining the procedure’s benefits.
Jennifer questioned whether the infant handed to her was indeed Nate, as she was certain he was healthy and didn’t need surgery. The nurse later verified the details and acknowledged that the pediatrician had mistakenly operated on the wrong baby. While the doctor apologized for the error, Jennifer immediately contacted her attorneys.
