Devastating Surgical Error Highlights Critical Need for Self-Advocacy
Patients who educate themselves and stand up for their rights have a better chance of survival
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William Bryan was vacationing in Florida with his wife when he started experiencing abdominal pain on his left side. After investigations at the hospital, a surgeon convinced him to get his spleen removed and said that if Bryan chose to leave the hospital without the surgery, he would experience serious complications.
Bryan reluctantly agreed to the procedure. However, during the operation, the surgeon mistakenly severed the major blood vessels supplying Bryan’s liver and removed his liver instead of the spleen. Bryan bled out on the operating table and died.
The liver is usually much larger than the spleen and is located in the upper-right portion of the abdominal cavity, while the spleen is in the upper left. A competent surgeon would not have made this fatal error.
The man’s distraught widow is calling for justice for her husband and wants to warn other prospective patients about the surgeon, according to an NBC News report. In a public service announcement, the family’s lawyer said there’s evidence this is not the first time the doctor has removed the wrong organ during surgery.
How and why does wrong-site surgery happen?
Wrong-site surgery is where a surgeon operates on the wrong body part or examines the wrong area during an invasive procedure. It is the most dramatic, visible, and devastating of all surgical errors. There have been news reports of cases where a surgeon operated on the wrong limb or eye, for example. Wrong-site surgery is harmful to patients and can even lead to their death. In many cases, the patient must undergo additional surgery and hospital time.
A case study in the Annals of Internal Medicine describes a situation where doctors mistook one patient for another due to a name mix-up and performed an unintended invasive cardiac electrophysiology study. Those reviewing the case discovered at least 17 separate errors, none of which could have caused this unfortunate event alone.
From 1995 to 2005, The Joint Commission found that wrong-site surgery was the second-most frequently reported sentinel event — a patient safety event resulting in death or harm. Across all surgeries, the overwhelming top contributing factor to wrong-site surgery was failure to follow protocol.
These discoveries were published in A Contemporary Analysis of Closed Claims Related to Wrong-Site Surgery in The Joint Commission Journal on Quality and Patient Safety. The findings led to The Joint Commission implementing the Universal Protocol for Preventing Wrong-Site, Wrong-Procedure, and Wrong-Person Surgery in 2003.
Following this, in 2008, the World Health Organization (WHO) launched the mandatory Global Patient Safety Challenge, Safe Surgery Saves Lives. This challenge aimed to make surgery safer worldwide by defining a safety standard that all WHO Member States could apply. After extensive consultation, the WHO developed a Surgical Safety Checklist to decrease errors and adverse events and increase teamwork and communication in surgery.
The checklist has three main components:
Sign-in (before starting anesthesia).
Time-out (after starting anesthesia and before surgical incision).
Sign-out (during or after surgery but before moving the patient out of the operating theatre). The 19-item checklist has resulted in a significant decrease in morbidity and mortality. The majority of surgical providers around the world now use it.
How can patients protect themselves?
Wrong-site or unnecessary surgery is preventable and should never happen. But, like all of us, doctors sometimes make mistakes. As a doctor’s daughter, one lesson I’ve always remembered from my father is, with health and medical matters:
“Be the squeaky wheel because that’s the one that gets fixed.”
People who lie quietly in hospital beds without asking questions or getting second opinions may die before those who advocate for themselves and speak up when they are not getting the treatment they need or expect.
Don’t just unquestioningly accept everything your doctor says. In the game of life, you don’t get extra points for being a good patient.
In a study published in the Journal of Patient Safety, researchers looked at the steps patients took after feeling unhappy with the service they’d received at a hospital in Queensland, Australia. The researchers proposed that it was necessary to determine the effectiveness of the hospital’s complaint-handling process from the patient’s perspective before they could use the complaints to help make improvements. In their conclusions, they noted,
“Healthcare professionals should take a more active role in identifying and responding to patients who are experiencing dissatisfaction but are not actively complaining. This level of vigilance and responsiveness will ensure opportunities to improve health service delivery and patient safety are not lost.”
A good doctor will encourage their patients to ask questions. They will not take it personally if a patient expresses concerns about their suggested treatment plan or wants a second opinion. A competent practitioner who has given sound advice will likely find the patient will return to them and follow their recommendations.
Patients who advocate for themselves have a better chance of survival
With our bodies and health, we should have the right to assert our best interests. However, many of us feel uncomfortable advocating for ourselves. We may not have seen our parents or teachers model this behaviour or had much practice with it. Sometimes, our past experiences or beliefs about whether our needs are valid prevent us from being assertive and fighting for our rights.
In a working paper published in the National Bureau of Economic Research (NBER), researchers reported a disturbing discovery of racial differences in C-section delivery. A large study of close to one million births at New Jersey hospitals found that obstetricians are more likely to unnecessarily perform C-sections on Black mothers with low risk factors than white mothers and that overall, Black women were 25% more likely to deliver by C-section.
Experts speculate about the reasons. However, further studies are required to reveal the motivation behind these surgeries. Unnecessary C-sections put women and babies at risk of medical complications like ruptured surgical wounds and also result in higher medical bills.
As a member of the Tri-Cities Community Action Team, based in Coquitlam, Canada, I regularly meet people who are struggling with substance use disorder. Many of these people turned to drugs initially to help cope with pain from physical injuries. Their doctors often prescribed opioids without offering alternate pain relief therapies, leading to a lifetime of addiction and misery.
Self-advocacy requires communicating our values and needs in a way others will understand. With practice, we can become more skilled in speaking up for ourselves. To advocate effectively, we need to find out what support, treatments and resources are available and learn as much about our situation as possible. We must then communicate clearly and ask questions about the available options.
Loved ones can support us during medical appointments
When speaking with a doctor about any serious health issue, asking a loved one to accompany us is wise. It’s also a good idea to do some research before medical appointments so we can ask intelligent questions. For many people, on hearing the words, “You have cancer” or some other life-threatening condition, they hear almost nothing afterwards. The doctor’s words just turned their world upside down, and the sudden grief and stress they experience at this moment reduces their ability to listen, understand and remember the doctor’s recommendations.
Having a companion there can be helpful as they can make notes, give information about our symptoms that we may not have the confidence to disclose and ask difficult questions on our behalf. After leaving the doctor, this person can check in with us and help ensure we have followed the doctor’s recommendations for recovery.
Some stoic individuals don’t want to be any trouble to the doctor and will suffer in silence rather than being a bother. Others are too embarrassed or ashamed to discuss their symptoms and conditions, which the doctor could have caught and treated early. They are sometimes left until it’s too late. There are also cases where the person is too sick or injured to communicate, and we may have to make tough decisions on their behalf.
We only have one body to live in for our entire lives, so taking good care of it is essential. It’s important to speak up if a medical professional suggests a course of action we are uncomfortable with. We must take responsibility for our health and wellness, maintain our records, seek clarification and explore our options before agreeing to a treatment plan. With medical issues, we can improve our chances of survival by being assertive.
Remember, if in doubt — speak out.
This story was originally published in Wise & Well on Medium
Gee, I got a letter of apology from the hospital, but it contains default phrases I’ve heard before. Is there a form letter for this, as there is for medical identity theft?