Medical Malpractice: Right Surgery, Wrong Patient, Big Trouble

It's easy to blame this case of wrong-person surgery on the pathologist who admittedly mixed up biopsy slides, but we're still left to wonder what if anything the OR team could have done to catch the case of mistaken identity and save a cancer-free patient from a radical prostatectomy that left him impotent and incontinent. The answer, sadly, might be there was little anyone in the OR could have done to prevent this case of wrong-person surgery.

Rick Huitt, who'd just retired after 41 years on the factory line at John Deere, was told by Iowa Clinic (West Des Moines) urologist Carl Meyer, MD, that he needed a radical prostatectomy. The problem? He didn't. Someone else did. Joy Trueblood, MD, a pathologist at Iowa Clinic, had mixed up slides of Mr. Huitt's non-cancerous tissue sample from his prostate cancer screening with those of another unidentified man who had extensive cancer.

After the unnecessary prostatectomy, Dr. Meyer sent Mr. Huitt's prostate to a pathologist at the Iowa Methodist Medical Center, who examined the gland and found no cancer. Dr. Meyer informed the Huitts of the finding, then sent the biopsy slides and the pathology specimen of Mr. Huitt's prostate to the Mayo Clinic, which confirmed the cancer-free diagnosis.

In their civil action, the Huitts accused Iowa Clinic of negligence in the handling, processing and reporting of cancer in Mr. Huitt's biopsy samples, which they said led to "permanent injury and damage" — specifically, physical and mental pain and suffering past and future, and loss of full mind and body past and future.

In court, Mr. Huitt's wife of 45 years and co-plaintiff, Judy, said the couple's active sex life was devastated by Mr. Huitt's post-operative impotence and incontinence, caused by nerve damage suffered during the surgery. She testified that his penis had become shorter, and that he needs to wear several urinary pads every day. "They never told us they were sorry. Never once," she told the Des Moines Register of Iowa Clinic.

It gets worse. The Register also reported that, according to Judy Huitt, the patient who actually had cancer was told he didn't, and wasn't correctly diagnosed for at least another 4 months.

Court records show the pathologist explained how she believed the mix-up happened. She testified that a barcode scanner read the barcode in a stack of papers and then, when she reported the findings, the incorrect patient was tied to the results. The pathologist went on to testify that this type of thing had happened occasionally over the previous 10 years, but that she'd caught previous errors. Her testimony also stated that she has changed the way she handles pathology documentation since the incident.

Iowa Clinic's insurance company, MMIC, mounted a defense that, by the time of the trial, acknowledged responsibility for the mishap, with Dr. Trueblood and Iowa Clinic's director of pathology admitting negligence, while also arguing that Mr. Huitt "sometimes had "urgency' issues with urination in the past, and that his other health issues could have led to erectile dysfunction in the future," according to the Register.

The defense further argued that Mr. Huitt didn't deserve the $15 million judgment he was seeking, stating that he could still mow his yard, attend the State Fair and pick up his granddaughters from school — all activities he loved. The head of MMIC's claims division argued that the case was worth $350,000; by closing arguments, that figure had risen to $750,000.

The Huitts and their attorney countered that such a verdict wouldn't be nearly enough.

When a doctor operates on the wrong patient, we rush to retrace the surgeon's steps in the hopes of pinpointing the mix-up that led to the mess-up in the OR. But what if the crucial error that set in motion the sequence of events that led to the case of mistaken identity occurred in a lab when a pathologist mistook biopsy samples on specimen slides?

How can your facility prevent a disastrous situation like this from occurring? The only possible doublecheck is to have surgeons question results that are significantly discordant with the operative findings. For example, if a surgeon biopsies an obviously neoplastic lesion and the result is negative, he should consult the pathologist. Even with this step, it may be impossible to untangle the error.

Unfortunately, mistakes happen as results of both human error and technology — whether independent of one another, or combined. This pathologist was aware of a previous error, but she didn't do anything to repair it, other than hope she would catch problems that happened in the future. Unstable clinical processes are prone to error and often lead to catastrophic outcomes.

It's easy to fall into bad habits over time, or jadedly accept bad situations and systems without speaking up. But a lot of those situations and systems could be improved with a little communication and collaboration. The most important preventative measure your center can take to avoid a situation like the one Iowa Clinic experienced is to encourage all of your personnel to report errors, near misses or any other data point that could result in a patient being put in harm's way. Creating, encouraging and adhering to this type of transparent, proactive environment will benefit both your patients and your employees. When staff feel comfortable reporting problems, or potential problems, a trust for and respect of management is created, and the ultimate beneficiary is the patient. OSM