Wrong-site surgery and its consequences
A Florida eye-surgery specialist, Dr Ira Perszyk has been fined and ordered to attend various training sessions after carrying out laser-eye surgery on a 91-year-old patient - he accidentally operated upon the wrong eye.
The patient was to receive a procedure - Selective Laser Trabeculoplasty (SLT), which is a laser surgery usually used to treat glaucoma - on their left eye. Preparatory notes for the procedure showed the doctors intent to treat the left eye, and his nurse prepared the left eye too. In an unfortunate error, Dr Perszyk then operated on the right eye in error.
It was reported on November 28 that the Florida Board of Medicine had adjudged that for making the error, Dr Perszyk will be fined $4,000 administrative fine and a further $2,526.06 to reimburse the investigation and prosecution costs.
He'll also have to take various education and re-training courses, for wrong-site surgery and a course in risk management - either that, or sit through at least an eight-hour day of Board of Medicine disciplinary hearings.
Wrong-site surgery - it happens
While cases of wrong-site surgery are thankfully not all that common, they do happen from time-to-time.
A 2020 study in the Journal of Patient Safety looked at cases of wrong-site surgery in the UK, and found that wrong-site surgery occurs in approximately 1 in 100,000 cases but could be as common as 4.5 in 10,000 cases dependent on the procedure being performed. This sounds like a low number, but consider that a similar study carried out by the National Institute of Health estimates that wrong-site surgery occurs around 40 times per week in hospitals and clinics in USA.
The consequences of such errors can be relatively trivial. In September 2019, a Tampa urologist - Dr Raul Fernandez-Crespo performed a vascular operation on a patient, inadvertently operating upon the wrong testicle, He too received an administrative fine and was ordered to attend re-training.
A more serious case happened in July 2021 when surgeons at a hospital in Ohio transplanted a kidney into the wrong patient. Fortunately the recipient of the kidney recovered, but the patient who should have received it, missed out on getting the organ they needed on that occasion.
The pressure of being a surgeon
There can be no doubt that doctors and surgeons experience immense pressure in their work and this cannot be overlooked. That they are skilled and caring enough to be able to help those with complex medical conditions is something nobody should take for granted.
Meanwhile, governing bodies in medicine are constantly reviewing processes to minimize the risks of wrong-site surgery occurring. It seems unlikely however that the risk will ever be fully-removed - human-error will always play its part.
Have you ever experienced wrong-site surgery, or heard of it happening to others you know? Let me know in the comments section below.
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