Doctors removed the wrong body parts or left medical equipment inside the bodies of hundreds of Americans last year, data shows.
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 report into these so-called ‘never events’ – accidents so egregious they should never happen – has laid bare how these cases have been on the rise since 2019.
Overall, 1,411 American patients dealt with the outcome of one of these mistakes 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 organization that provides accreditation and reports on incidence data from international hospitals. Their annual report deems never events as ‘sentinel events’ because: ‘they signal the need for immediate investigation and response’
Though this year saw a slight dip compared to 2022, the total number of these events has been up overall since 2019, according to Professor Adam Taylor from Lancaster University in the UK.
Writing in The Conversation, he said there had always been less than 1,000 per year prior to an uptick that began in 2021.
Professor Taylor said: ‘This type of medical error is known as a never event, because it should never have happened. Unfortunately, they happen all too often.’
The most common mistakes included falls, incorrect surgeries, and objects left behind in patients’ bodies.
Eighteen percent of all of these events resulted in death – representing an estimated 253 people. Fifty-seven percent, roughly 804 patients, suffered from severe, but temporary harm.
The vast majority of the never events – about 48 percent – were falls, affecting about 670 patients.
These generally occurred when someone was walking, lying in bed or using the restroom without being observed. About two dozen of these falls resulted in death and 56 resulted in permanent harm.
The remaining 538 falls caused severe, but temporary damage.
Next, there were 112 incorrect surgeries performed last year, a 26 percent increase from 2022.
These included surgeries in which 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 seven percent of cases, the wrong implant was placed. In 12 percent, doctors operated on the wrong patient, in 19 percent they performed the wrong procedure, and in 62 percent of cases the wrong body part was operated on.
None of these resulted in death or permanent disability – but 39 percent caused severe temporary harm.
Incorrect surgeries most commonly occur when doctors operate on the wrong side of body if performing a procedure on an organ that has a symmetrical mate, such as the kidneys, Professor Taylor wrote.
This happens when scans are placed on the screen the wrong way, when clinical reports fail to mention which side of the body is damaged or they mistakenly report which side is diseased.
The number of wrong surgeries and objects left in the body saw a slight increase since 2022, even though the total number of sentinel events were down from the previous year, according to The Joint Commission’s report
This adverse events report comes from the Joint Commission, a US-based private, not-for-profit organization that reports on hospital and healthcare data from across the world. It has been releasing data about these events since at least 2013.
The report found in 2023, there were 110 patients who had foreign objects left in their body – an 11 percent increase from 2022.
Among the objects 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 miscellaneous mixture of other tools – one case reported surgical scissors left in the body.
After foreign objects, there were 106 cases of assault, rape, sexual assault or homicides involving hospitalized patients in America in 2023, according to the report.
Half of these were patient-on-patient, 28 percent involved staff-on-patient and 13 percent involved a patient acting on a staff member.
Finally, there were 81 cases where patients had treatment delayed unnecessarily and 71 cases where patients committed suicide while at the hospital.
Carolyn Boerste went in for a treatment to improve blood flow but ended up with a sponge sewn into her, which eventually caused her to need an amputation
Albert Hubbard, pictured, wrongly had a kidney removed after a doctor reportedly mistakenly read the CT scan of another man with the same name
William Bryan, a 70-year-old from Florida, died last month after his liver was removed during a surgery instead of his spleen. And he is only the most recent in the public cases of never events.
In 2011, Carolyn Boerste, a Kentuckian who was 54 at the time, underwent surgery to improve blood flow to her legs. When surgeons cut a wrong blood vessel during surgery, they used a sponge to soak up the blood.
But they forgot to remove the sponge before sewing Ms Boerste up – leading to severe stomach problems, infection and an eventual leg amputation.
In 2019, Albert Hubbard, a man from Massachusetts, had one of his kidneys removed in emergency surgery after his doctor reportedly read the wrong CT scan.
The actual man who needed the kidney surgery was faced with delayed care.
Whatever the cause behind these missteps, many court cases involving never events have yielded big settlements for patients.
International payouts for never events between 1990 and 2010 totaled more than $1.3billion.
Ms Boerste, the Kentucky patient, was awarded $10.5million in damages in a suit against the University of Louisville Hospital in 2020. Mr Hubbard’s lawsuit against his doctor appears to still be pending.
In order to decrease the number of sentinel events, Professor Taylor said international organizations have looked at improving operating room and hospital policies.
For example, in 2008, the World Health Organization created a surgical safety checklist. This has questions aimed to help providers pause and confirm 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 decreased 36 percent. Though this is encouraging, Professor Taylor said, it’s not perfect.
He added: ‘However, as the statistics on never events show, there is still plenty of room for improvement. As the demand for healthcare increases, systems have to adapt to ensure patient safety is not compromised.’
