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Florida surgeon ‘devastated’ over death of patient after removing liver instead of spleen
(www.theguardian.com)
Thomas Shaknovsky botched the surgery of William Bryan, 70, who died on the operating table
According to Shaknovksy’s deposition, after removing Bryan’s liver, the surgeon instructed a nurse to label the organ as a “spleen” – and he also identified it as a spleen in Bryan’s postoperative notes. Shaknovsky later said he had been “mentally compromised” at the time of Bryan’s death, explaining that he was “devastated, demoralized, crying over his passing, felt that I failed him”.
Though this was an idiocity, I think we need to be careful with just blaming the surgeon and that's it.
Errors like this usually happen because of a chain of various circumstances and other little mistakes, like with airplane crashes.
I think it would be much better that we treat these sort of incidents like airplane crashes. Investigate everything that went wrong, all causes, without focussing on guilt during the investigation. Guilt can be determined from the results of that, but primarily I want that we get data on how this happened in the first place, and what we can do to avoid this from happening again. This strategy was highly successful in aviation, I'd like to see that applied here too because too much shit still goes too much wrong in healthcare
It's been a while since I've operated on anyone (consentually, at least). I know some doctors can be so arrogant that you don't ever want to second-guess them or correct them for fear of bring berated. Aren't there other people directly over the patient who might butt in and say "hey, are you sure that's the right part?"
The article is kinda shit and gives no information but usually there would be multiple eyes on the patient. You have at minimum the rotating nurse (not scrubbed in,) the scrub tech (sterile and knows every step of the operation,) the anesthesiologist or CRNA (wouldn't have a good view of the site), and a resident or PA assisting. There would have been eyes on the patient, which is what makes it so confusing. Maybe the surgeon was intimidating and nobody felt they could speak up against him?
https://www.namd.org/journal-of-medicine/3293-surgeon-removed-liver-instead-of-spleen-family-says.html This article is better than the one in the post but doesn't answer the big question, which is how many people had eyes on the patient?!?!? It's difficult for me to believe that a surgeon with experience could make this kind of mistake without inebriation being a factor. The article describes the organ removed as "grossly" obviously a liver, grossly in this case meaning you can see it with your eyes and don't need special tools. I can't imagine making this mistake and I'm not even a surgeon I just went to med school. Absolutely insane case and I wonder how many other people this doctor harmed.