What Would I Have Done? Learning From the Mistakes of Others

Periop Times Timely Insights for Today’s Perioperative Nurse Lessons Learned Sharing Your Stories and Advice The Stitch

By: Melanie Perry, BSN, RN, CNOR, CSSM

Published: 2/8/2025

Share:

On August 21, 2024, William “Bill” Bryan died in the OR after his surgeon, Dr. William Shaknovsky, mistakenly removed Bill’s liver instead of his spleen. Mr. Bryan was scheduled for a laparoscopic splenectomy, but during the operation, “Shaknovsky removed Bryan’s liver and, in so doing, transected the major vasculature supplying the liver, causing immediate and catastrophic blood loss that resulted in  death.”1 

The surgeon removed the liver, had it labeled as “spleen,” and sent to pathology. He also informed the family that Bryan’s “spleen” was “so diseased that it was four times bigger than usual and had moved to the other side of his body.”1 Pathology results identified the tissue as liver tissue, and during the autopsy, Bill Bryan’s spleen was still in his body and located in the expected anatomical location. 

A Sobering Reminder 

When I hear stories like this one, I’m left dumbfounded and aghast that something so egregious could occur. But these stories also serve as a sobering reminder of the serious responsibility that we all have when it comes to patient care and patient safety.  

There isn’t any information available about what communication or conversation occurred in the OR the day that Bill Bryan died. I wasn’t there, and I don’t know what happened. But I can read the story, and as a perioperative nurse, I can mentally put myself into that situation and think, “What would I have done?”  

An Act of Self-Examination 

This is a very healthy exercise to engage in whenever we hear stories like this, because we have an opportunity to think through a situation, discuss it, and learn from it. And we can do it from a very low-risk perspective— it’s an act of self-examination; there’s no patient on the table. You can also carry this one step further and engage in a conversation with a preceptor or nurse mentor. This allows you to discuss different options, see the situation from different angles, and learn from the experience and perspective of others. 

Questions to Ask 

So, if we take any event, whether it be a sentinel event like this one, a near-miss event, a code, or even an unexpected trauma situation, we can take what we know, both about the situation and perioperative nursing, and ask ourselves the following questions: 

  1. What would I have done in this situation?
  2. What mistakes were made and how can I learn from this event so that I don’t make those mistakes?
  3. What actions could I have possibly taken to contribute to a different outcome? 
  4. Do I feel empowered to speak up, to “stop the line”? If the answer is no, why not?
  5. What knowledge can I take from this scenario or situation and apply to my practice? 

These questions aren’t to assign blame but to help us pause for introspection. We can ask ourselves these questions whether we were involved in the event and we’re analyzing it later, or when we’ve heard about an event, and we want to put ourselves into that situation to think it through.  

When we can think through a scenario outside the stress of the moment or the craziness of a surgical case, we can more clearly and calmly examine the events and analyze how we might or might not have acted in that situation. Sidebar 1 provides an example scenario for self-examination. 

Sidebar 1. Example Scenario for Self-Examination 

Let’s think through another scenario and answer the questions: 

Julie, RN, and Amanda, CST, are assigned to an exploratory laparotomy. The case was added on later in the day, which means the case will run after hours. Julie and Amanda have already worked their regular shift, and they will be required to stay after to finish the case. Julie and Amanda work together to count instruments and soft goods prior to beginning the case. The patient is positioned, prepped, and draped according to the surgeon’s preference, following all guidelines. As the surgeon begins to close, Julie and Amanda perform their first closing count. All counts are correct. The surgeon finishes closing, the surgery is complete, and the patient is transferred to the PACU for recovery.  

Two days later, the patient is experiencing uncontrolled abdominal pain. An abdominal x-ray reveals a lap sponge in the patient’s abdomen, near his incision. The patient is returned to the OR where the retained lap is removed.  

After the second case, Julie reflects on the sequence of events during the first case. Our counts were correct, how did a lap get left behind? While analyzing their case, Julie realizes that she and Amanda did their first closing count, but they failed to do a final count after the surgery was complete. She admitted to being tired and simply forgot to perform another count.  The surgeon also admitted to placing a lap in the abdomen after the first count, but he did not alert the room to the lap placement.  As a result, the lap was missed and closed in the patient’s abdomen.  

  • What would I have done in this situation?
    • A final count should always be performed to ensure all instruments/soft goods are accounted for. I could also take advantage of any adjunct technology, including sponge counting bags, to assist in visualizing the presence of all lap sponges.  
  • What mistakes were made and how can I learn from this event so that I don’t make those mistakes? 
    • The final count was forgotten, due to fatigue and oversight. I can learn from this event because we all get tired, and we all work long shifts, but I can write a reminder on the white board, I can make a note on my paperwork, and I can communicate when we need to count with the whole team so that we all work together to remember to count at the appropriate times.  
    • The surgeon didn’t announce the lap placement to the room. This can be used as an opportunity for reminding our surgeons about communicating with the team.  
  • What actions could I have possibly taken to contribute to a different outcome? 
    • I could have performed a final count and used adjunct technology to confirm it.  
  • Do I feel empowered to speak up, to “stop the line”? If the answer is no, why not?
    • Yes, I know that I can ask to count at any time and my team will work with me to confirm our counts.  
  • What knowledge can I take from this scenario or situation and apply to my practice?
    • I can use this example as a powerful reminder of how quickly items can be left behind during a case. My priority is the safety of my patients, and I can help to ensure their safety by always performing surgical counts with my scrub person. Using adjunct technology will also help to confirm our counts.  

The Opportunity 

I can’t imagine how the OR staff who were part of that case feel, and I would never presume to know what happened in that room. I can only see what’s been reported. But in reading the news stories, there is an opportunity for all of us to learn and to accept yet another reminder that our role as perioperative nurses comes with great responsibility.   

We take this responsibility seriously, and we embrace every opportunity to learn and improve, even from our mistakes or the mistakes of others. As the famous quotes says, “You must learn from the mistakes of others. You can't possibly live long enough to make them all yourself." 

References 

  1. Planas A. Florida surgeon mistakenly removes patient’s live instead of spleen, causing him to die, widow says. NBC News. September 4, 2024. Accessed February 1, 2025. https://www.nbcnews.com/news/us-news/florida-surgeon-mistakenly-removes-patients-liver-instead-spleen-causi-rcna169614 

AORN Resources 

Open access: 

If your facility subscribes to AORN eGuidelines+: 

Related Articles