Data shows that doctors removed the wrong body parts or left medical equipment inside the bodies of hundreds of Americans last year.
A story about a 70-year-old Alabama man who died when surgeons removed his liver instead of his spleen shocked the nation earlier this month.
Now, a A report on these so-called “never events” – accidents so heinous that they should never happen – has revealed how such cases have been increasing since 2019.
In total, 1,411 American patients suffered the consequences of one of these errors in 2023 – roughly the equivalent of three people per day – and more than 200 patients died last year.
In August 2024, William Bryan died after surgeons removed his liver instead of his spleen. He leaves behind his wife of 33 years, Beverly Bryan.
The Joint Commission is a US-based organisation that provides accreditation and reports on incidence data for international hospitals. Its annual report considers previously unseen events to be “sentinel events” because they “indicate the need for immediate investigation and response.”
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Although there was a slight drop this year compared to 2022, the total number of such events has generally increased since 2019, according to Professor Adam Taylor of Lancaster University in the UK.
Writing in The conversationHe said there had always been fewer than 1,000 per year before an uptick that began in 2021.
Professor Taylor said: “This type of medical error is known as an ‘unlikely event’ because it should never have happened. Sadly, they happen all too often.”
The most common errors included falls, incorrect surgeries and objects left on patients’ bodies.
Eighteen percent of all these events resulted in death, representing approximately 253 people. Fifty-seven percent, approximately 804 patients, suffered serious but temporary injuries.
The vast majority of never-occurred events (about 48 percent) were falls, affecting about 670 patients.
Typically, these falls occurred while someone was walking, lying in bed, or using the bathroom while unobserved. About two dozen of these falls resulted in death, and 56 resulted in permanent injuries.
The remaining 538 falls caused serious but temporary damage.
In addition, 112 incorrect surgeries were performed last year, an increase of 26 percent compared to 2022.
These include surgeries where the wrong implant was placed, the wrong patient was operated on, the wrong procedure was performed, or the wrong body part was operated on.
In 7% of cases, the wrong implant was placed, in 12% of cases doctors operated on the wrong patient, in 19% of cases they performed the wrong procedure, and in 62% of cases they operated on the wrong body part.
None of them resulted in death or permanent disability, but 39 percent caused serious temporary damage.
Incorrect surgeries most commonly occur when doctors operate on the wrong side of the body if they are performing a procedure on an organ that has a symmetrical partner, such as the kidneys, Professor Taylor wrote.
This happens when scanners are positioned on the screen incorrectly, when clinical reports do not mention which side of the body is damaged or incorrectly report which side is diseased.
The number of surgical errors and objects left in the body increased slightly from 2022, although the total number of sentinel events decreased from the previous year, according to The Joint Commission’s report.
This adverse event report comes from the Joint Commissiona private, non-profit organization based in the United States that reports on hospital and healthcare data from around the world. It has been publishing data on these events since at least 2013.
The report found that in 2023 there were 110 patients who had foreign objects left in their bodies, a Increase of 11 percent from 2022.
Among the items mistakenly left behind, 35 percent were sponges, 10 percent were guide wires and eight percent were fragments of medical instruments.
The remaining 47 percent was a mix of other tools (in one case surgical scissors were reported to be in the body).
After foreign objects, there were 106 cases of assault, rape, sexual assault or homicide involving hospitalized patients in the United States in 2023, according to the report.
Half of these cases were patient-to-patient, 28 percent were staff-to-patient and 13 percent were a patient acting on a staff member.
Finally, there were 81 cases where patients had to unnecessarily delay treatment and 71 cases where patients committed suicide while in hospital.
Carolyn Boerste underwent treatment to improve blood flow but ended up with a sponge sewn inside her, ultimately resulting in her needing an amputation.
Albert Hubbard, pictured, had a kidney removed by mistake after a doctor mistakenly read the CT scan of another man with the same name.
William Bryan, a 70-year-old Florida man, died last month after his liver was removed during surgery instead of his spleen. And it’s just the latest case of facts that were never known.
In 2011, Carolyn Boerste, a then-54-year-old Kentucky woman, underwent surgery to improve blood flow to her legs. When surgeons cut the wrong blood vessel during surgery, they used a sponge to soak up the blood.
But they forgot to remove the sponge before stitching Ms Boerste up, leading to severe stomach problems, an infection and eventual leg amputation.
In 2019, Albert Hubbard, a Massachusetts man, had one of his kidneys removed in emergency surgery after his doctor reportedly read an incorrect CT scan.
The man who really needed kidney surgery faced delayed care.
Whatever the cause behind these errors, many court cases involving events that never occurred have resulted in large settlements for patients.
International payments for events never seen before between 1990 and 2010 totaled more than 1.3 billion dollars.
Ms. Boerste, the Kentucky patient, was awarded $10.5 million in damages in a lawsuit against the University of Louisville Hospital in 2020. Mr. Hubbard’s lawsuit against his doctor appears to remain pending.
To reduce the number of sentinel events, Professor Taylor said international organisations have sought to improve operating theatre and hospital policies.
For example, in 2008, the World Health Organization created a surgical safety checklistThis article has questions intended to help providers pause and confirm that they were operating on the right patient in the right area and that all the tools they began the surgery with were accounted for at the end.
Since it was introduced, complications after surgery have fallen by 36 per cent. While this is encouraging, Professor Taylor said, it is not perfect.
He added: “However, as statistics on events that never occur show, there is still much room for improvement. As demand for healthcare increases, systems need to adapt to ensure patient safety is not compromised.”
