from Study Finds:
A 70-year-old man from Alabama recently died at a hospital in Florida when a surgeon mistakenly removed his liver instead of his spleen.
This type of medical error is known as a “never event” because it should never have happened. Unfortunately, they happen all too often.
Never events range from the wrong organ or side being operated on, the wrong prosthesis (such as hip joints) being inserted, to foreign objects (typically surgical instruments and swabs) being left inside the patient.
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In the UK, provisional NHS data shows that between April 2023 and March 2024, there were 370 never events. In the three years prior to that, the figures were, in reverse order, 384 (2022-23), 407 (2021-22) and 364 (2020-21). So, roughly, one of these events occurs each day. Given the number of procedures performed daily by the NHS, these figures are impressively low. Although I suspect that would be cold comfort for anyone affected by one of these often life-changing errors.
In the US, there has been a recent increase in never events, with 1,440 in 2022 and 1,411 in 2023. Before this, never events were less than 1,000 a year. In 2023, 18% of these events resulted in the patient dying and 8% in permanent harm or loss of function.
What are the most common errors?
Considering the man from Alabama, it is difficult to see how a surgeon might confuse the spleen and liver given that the basics of anatomy are taught early in medicine. And then, the subsequent years of postgraduate training see doctors focus on areas of their specialty, such as general surgery, orthopedics, neurology, and others, which further reinforces their knowledge of their chosen specialty region.
Many surgical careers take at least 15 years of medical training to achieve in the UK and similar lengths of time in the US and elsewhere. However, it is well recognized that where these errors take place, they are often multifactorial.
The most common errors are seen on the wrong side of the body. Humans are symmetrical in many ways, with pairs of various organs, so confusion over the left and right happens.
In urology, studies have shown that in over 10% of cases clinical letters fail to mention the diseased side (8.7%) or they mention the wrong side (3.3%). And sometimes radiology images are placed on the screen the wrong way around. These things can lead to patients having their healthy kidney removed rather than the diseased one.
Other paired structures that are often removed from the wrong side are testicles, which can leave patients infertile.
Similar surgical errors have affected women’s fertility, with surgeons removing the wrong uterine (fallopian) tube. In other errors, healthy ovaries have been removed or, at least in one case, removed in error (it should have been the pregnant woman’s appendix that was removed), sadly leading to the patient’s death.
A study from the US suggests that the most likely surgical specialty to perform wrong-site surgery was orthopedics (35%), followed by neurosurgery (22%) and then urology (9%).
Others have confirmed orthopedics as having one of the highest rates of wrong-site surgery – 21% of hand surgeons confirmed they’d operated on the wrong site.
