The last thing a patient wants to hear while at the hospital is "Oops!" but mistakes certainly do happen. These surgeons admit the biggest gaffes they've made while having someone under the knife.
The Doctor Did What With The Specimen?!
“Surgical tech here.
We were doing a skin graft on a burn patient. In those types of surgeries, you have two different operative sites IF you’re taking the skin graft from the patient and not using cadaver skin. This means I have two different surgical teams going and only one me bouncing back and forth assisting them.
This was also at a university hospital, meaning I have attending surgeons, residents, and medical students all working alongside. If you work in surgery, you know that unless you’re the tech, YOU DO NOT TOUCH THEIR TABLE OR ANYTHING ON IT.
As we’re doing the skin harvest, you have to keep the skin moist until it’s ready to be transplanted on the site. I wrap mine in damp sponges and keep it on my table. I bet you can see where this is going. I turn back to my table and it’s gone. I look everywhere and finally stop everyone from working to ask who has the damp sponge that was on my table. A resident told me my table was too cluttered and he threw the sponge in the trash. I saw red. I’ve never had to scold a doctor so bad in my life. Not only did he touch my table, but he also threw away an item that needs to be accounted for after surgery, and it had the specimen in it. Since the skin is no longer sterile, we had to use cadaver skin and, you know who pays for that? The PATIENT.
So, a note to all the baby docs, please don’t touch your scrub’s table unless we okay it.”
At Least They Were Able To Laugh It All Off
“Malpractice stories can be tough. I’ll lighten the mood a bit. Was doing varicose veins surgery on a very posh middle-aged lady. Very cut class accent. There was an anesthetic that we used that sometimes induced some hallucinations either going under or coming out of anesthesia and heard some funny things. Anyway, this lady was in recovery just coming out of the anesthetic. The team was around waiting for her to wake up and gag a little on the tube in her throat (for breathing) so we knew it was time to remove it. She gagged, we removed the tube, she smacked her lips and said loudly, in her incredible accent: ‘That’s the best piece of head I have had in years!’ The whole recovery room just fell about laughing. Luckily she didn’t remember it.”
A Nurse Shares Some Mistakes That Cost Lives
A nurse went to change a surgical dressing per order and misunderstood the order for how to dress it. Rather than ask questions after removing the surgical cover dressing, she cut the stitches in a midline abdominal incision and packed the wound with wet gauze, opening a brand new surgical wound and causing it to split open to the fat layer. She then recovered the wound with a cover dressing, which the night shift nurse didn’t check, because the dressing wasn’t ordered to be changed at night and there was no reason to look beneath it. It wasn’t noticed until the next night because the next day shift RN was busy addressing emergencies and ran out of time to change it, so the night shift nurse stepped up and found the wound dehisced.
A nurse assisting in the imaging center obtained an order for an anti-anxiety medication called Versed to be given to a patient getting an MRI. This patient had issues with claustrophobia, so this was necessary to obtain good images with the patient. The nurse went to search for the meds in the pyxis machine, to override pull it because in the short term, ordered meds like this won’t come up in a reasonable amount of time to wait for it to automatically show up under the patient’s name. So she has to type it in as a Google search in the screen to pull the medication. She types in only ‘Ve,’ which pulls up relevant medicines by alphabetical order, and without looking, clicked the first thing and gave it to the patient. It was only when the patient suffocated that they found out what happened. When she typed ‘ve,’ the first medication alphabetically wasn’t Versed, it was Vecuronium. The difference being an anti-anxiety med, versus a paralytic med, which paralyzed them while conscious and suffocated to death.
The nurse places a nasogastric feeding tube in a comatose ICU patient for tube feeds. Basically, a tube through the nose down to the stomach so the patient can eat while in a coma. The nurse starts the tube feed before getting an XRAY to confirm appropriate placement. The tube was in the wrong place. Due to some major misfortune, the tube ended up on the brain, and killed the patient.”
This Nurse’s Second-Guessing Saved A Life
“Surgical ward nurse here. The worst I’d seen was a bloke who’d managed to get to the operating theatre for an inguinal hernia repair – but had completely forgotten to tell anybody. The doctor/nurse hadn’t bothered to ask, about his medical history; otherwise young, fit, healthy bloke so no recent blood work had been done either.
Within a few minutes of returning to the ward, his surgical incision was starting to fill. It almost looked like an IV drip had tissued and his lower abdomen was filling with the IV fluids (rather than go into the veins and around the body, bagged fluids start filling up the surrounding tissue, etc). But of course, no one put any fluids down there.
I was still a grad then, but I’d seen enough post-op hernias to know something wasn’t right. I called the on-call doctor, who at the time, was only a medically trained junior. He took a cursory glance at it, told me he wasn’t a surgeon, was probably some local (anesthetic), and said he had another real emergency to go to on the med floor (but would come back to check on it after that).
I just knew something was terribly, terribly wrong and started an almost police level interrogation as to if there was something he might have forgotten to tell the doctors. No judgments etc. I needed his 100% honesty. I could have used the Chris Pratt meme when he admitted he had a condition called ‘thrombocytopenia’ but he didn’t know what it was and was too afraid to bring it up (and just assumed the doctors etc somehow know).
I then called the doctor back immediately and told him with or without him my next call would be to transfer the patient immediately to our department of emergency. The doctor was obviously happy with the same and told me to do what I needed to do (still had his emergency but would verify any highest level transfer request etc I’d make).
Thankfully, we caught it quite quickly, and he only needed a couple of bags of blood and some medication to restore hemostasis (normal bleeding/clotting, etc). He was apparently discharged home safely the day after.”
You Would Think A Surgeon Could Afford Better Glasses
“Not the surgeon, and I’m sure not even sort of his biggest mistake, but this was one of the more bizarre things I’ve witnessed in an OR. The surgeon brought a bad pair of glasses.
So here we are, total hip replacement. The surgeon is going to town with what I lovingly call the human grater, which is a doohickey to make sure the new hip socket will fit in. Picture a cheese grater wrapped around a golf ball on the end of a power drill. It’s not pleasant.
Anyway. The dude’s grinding away at the feller’s hip and suddenly yelps in surprise and stops, backing quickly away from the table.
We’re all like, the heck?
His glasses spontaneously broke in half. They were the type that didn’t have rims, just lenses with a bar across the nose and bars for the ears. So the metal crossing the nose snapped at the bolt.
The surgeon quickly starts stripping off his gown, etc., (had the full face shield get-up, ortho ORs are… splashy) and leaves the room. Comes back with a roll of tape. He and the circulating nurse can’t get them fixed, so he just holds them to his face and has her run the tape around his head a few times.
Then suits up again and goes back to acting as if nothing happened.
All-in-all added like 10 minutes to surgery time, at least that I could catch directly. Hadn’t been with that surgeon before, but I can’t imagine that was his best performance afterward. Seeing as how his glasses were taped across his eyes at weird angles.
But yeah, don’t buy $5 readers for the OR.”
Sweating Under The Stress
“Not properly a mistake, but kinda gross. I’m a medical student, I was watching a Caesarean birth and the first surgeon wore his mask just on his mouth, not covering his nose. He was a big name there so no one said anything (strange but not the strangest thing I’ve ever seen). When was the moment to stitch it all up after the baby was born, there was internal bleeding, not massive but no one could say where the blood was coming from. The surgeon is a bit troubled and starts to sweat. The fact is that his mask doesn’t cover his nose so I swear I see a lot of drops of his gross sweat falling into the woman abdomen. I pointed it out silently to the second surgeon who put the man’s mask in place. The surgery ended well, and I was disgusted while laughing like crazy with the other two students who were watching with me.”
They Left An Instrument WHERE?
“I am not a surgeon but I was a scrub nurse for decades. My worst moment ever was being told we had left an instrument inside a patient. Now that is our job – count, account, count again, account again, and repeat. I had always prided myself on knowing exactly where all my instruments were at all times. Now you have to realize we can have hundreds of items out but at the end of a case, we go through the trays again and double triple check.
So where the bloody heck had it come from? Even our CSSD staff(central sterilizing services department) hadn’t alerted us that anything was missing so what the heck? Turns out the patient hadn’t been well post-op and had a barium X-Ray. Barium was put into the bowel through a tube in the rectum and the tube was then left in place, clamped and the clamp placed on the abdomen. Cover said patient with a sheet whilst X-Ray was done and HELLO one clamp showing on X-Ray.
I saw the film and it was scary but the surgeon and I said straight away it wasn’t one of our surgical instruments and if they had just showed us straight away we could have avoided the panic. The poor patient was even told! Brought to theatre for removal of the clamp they were delighted to be told what had actually happened. A day we never ever forgot.”
His Mom, The Surgeon, Pulled A Nice Joke On Him
“I had brain surgery a few months ago. They put a shunt in (my first one) so it goes from the center of my brain to my abdomen. When I woke up I vaguely remember him saying my intracranial pressure was really high. After a few days in the ICU from a brain bleed that luckily healed on its own, I went home. I get to my post-op and ask him how high it was (thinking he measured it as you would during a spinal tap). So then this lovely conversation happened:
Surgeon: ‘Oh we didn’t measure it!’
Me: ‘How do you know it was high then?’
The surgeon smirks and does a half-laugh ‘Well, I drilled through your skull and of course spinal fluid comes out. But with you it was so high as soon as I got through your skull it shot out, covering me AND the wall behind me.. never seen anything like it… and I had to get a new gown!’
My mom, the surgeon and I had a good laugh at that
I imagine there were some swears while trying to managethe situation, and I wish I was awake to hear it. I had to wait three years for this surgery because no one believed I was suffering as much as I was and he believed me and fixed it. Endlessly grateful for all surgeons and nurses. You guys are heroes.”
This Guys Has Seen His Share Of Mishaps
“13 years in practice as a surgeon. Thus far so I haven’t had any major operative eff-ups.
However, everyone who is a surgeon gets their training at some kind of academic medical center. The mentors at these places tend to be of two varieties- type 1: The highly competent role models and type 2: Surgeons just barely competent enough to stay in practice but with their mistakes frequently reviewed publicly for educational purposes by the trainees who also work at the same facility so they can call those of type 1 for rescue help during the operation.
By far the most common mistake made by type 2 surgeons is doing operations in patients that were beyond hope of recovery. This frequently results in suffering for everyone involved and many times a more expeditious death for the patient with a terminal illness. A good example would be attempting to resect large, unresectable metastatic cancers wrapped around sensitive vital structures.
Some type 2 surgeons make careless mistakes like how I watched a vascular surgeon that forgot to reverse the vein graft when doing a bypass so that all the valves are pointed the wrong way and the graft doesn’t flow. I also once saw a cancer surgeon use the ultrasonic dissector to accidentally divide the external iliac artery. Have heard about inadvertent vascular injuries to the iliac vein and aorta. All but the last of those were identified and corrected with the patient suffering no adverse consequence.
Lots of times bowel injuries are missed and the patient has to go back to surgery for resection or repair. That’s super common because the vowel is pretty thin and fragile and partial thickness tears can breakdown in unhealthy patients with a lot of previous surgery and lots of adhesions. Even great surgeons get leaks once in a while for all kinds of reasons, but most commonly overconfidence in a really sick patient’s ability to heal a technically proficient surgery.
Sometimes timing an operation or part thereof is the most critical thing- having good enough blood pressure, heart rate, oxygenation, and nutrition are just if not more important for some types of surgery where functional organs are reconstructed rather than just being removed.
There are some common sayings among surgeons and one of these is ‘It takes five years to learn how to operate, ten years to learn when to operate, and a lifetime to learn when not to operate.”
Hey At Least This EM Is Honest!
“Not surgery, but EM. Perhaps it’s less shocking because we have a more chaotic environment but I’ve lots of stories.
Many years ago, trying to straighten out some fractured forearm bones, I managed to dislocate the wrist. The patient was very likely headed to surgery anyway but I tried so hard that I made it worse.
I’ve given activated charcoal to an overdose patient that then progressed to needing intubation, much more difficult to do when everything in the back of the throat is pitch black.
Sometimes one injects too much local anesthestic and it distorts the tissues, making it more difficult to close a laceration in the best cosmetic way. It’s a fine line listening to the patients that always want more painkiller but also want a pretty result.
I once saw a kid with a runny nose the night before his parents had tickets to fly to Disney. Silly me, I examined his ears. Although no ear symptoms, he had a bright blue piece of plastic in his ear. Therefore I felt obligated to get it out. Kid is not cooperative. Sedation. Lack of success (multiple docs tried). In this situation we usually discharge to go to ENT clinic tomorrow, but they had morning plane tickets. I don’t recall if they rescheduled their plane tickets or went to Disney with asymptomatic ear plastic, but after hours and hours fruitlessly messing around with me, I feel I probably ruined their Disney trip either way.”
This Surgeon Now Has A Lawsuit On His Hands
“I am not a surgeon, but I have a story of this. May 27, 2020, my 8-year-old grandson goes to his ENT doctor/surgeon for his surgery to have a cyst removed from his thyroid gland. Because of Covid, my daughter-in-law had to wait in the car in the parking lot. Simple surgery – go in in the morning, go home in the afternoon. An hour later my son calls me (he’s the dad); something went wrong and my grandson is being rushed by ambulance to the local hospital with a children’s wing.
The damage was so severe that the surgeons there didn’t know what to do. The original surgeon had cut my grandson’s vocal cords, and he cut a hole in his larynx. They called to talk to experts at Seattle Children’s Hospital. My grandson has been sedated and ventilated the entire time. The following day, the doctors recommend my grandson be flown to Seattle Children’s Hospital. Mom gets to fly with my grandson, my son drives over by himself. They arrive Friday morning, the new surgeon does the six hour repair surgery from 5-11 p.m. Friday night. My grandson spent the next week under sedation and on the ventilator, and then the new surgeon opened my grandson up and told my son and daughter-in-law that everything looks better than he had even hoped for.
The surgeon had three-goal priorities:
1. That my grandson would be able to breathe on his own and not need a tracheotomy.
2. That he would be able to eat and swallow on his own.
3. That he would still have his voice.
After two weeks in Seattle, they came home and my grandson is doing fantastic!!! He does have to go to Seattle to see his wonderful surgeon every few months to have scar tissue scraped from his vocal cords. But he is doing awesome, and that surgeon succeeded in meeting every one of his goals! Two other items – my grandson has wanted to be a voice actor since he was 4 years old. The original surgeon that messed up called my son and told him that once he opened my grandson up, he saw that it was not a cyst on his thyroid gland, but a lymph node. Yet he continued to perform the surgery!! Yes, my son and daughter-in-law have a malpractice suit against this doctor.”
These Folks Performed The Operation On The Wrong Person!
“Well…storytime. I’ve spent some 12 years in the ORs of various hospitals as an anesthesiologist now and have a ton of stories to tell. I’ll just list a few highlights –
This one time a surgeon did a gastrectomy on a patient posted for mastectomy. Two patients with the same name and age but different surgical units. No one bothered to cross-check details and things went wrong. The whole thing was explained as a medical necessity and swept under the carpet.
First-year resident learning to do an appendectomy without any supervision and by the end of four hours, I had to convert to GA because the spinal anaesthetic had worn off. Just before going under.. the patient revealed that she had already had an appendectomy as a child!!!
During cardiac surgery.. the surgeon had a bad habit of putting an intravenous cannula into the left ventricle to empty it while coming off cardiopulmonary bypass. This one time he went through the main blood vessel supplying the heart and the patient died on the table eventually. The patient was less than thirty years old.”