Surgeon operates on wrong side of brain — time-out compliance is questioned

Do some team members think they don’t have to participate?

A wrong-site surgery resulted in a medical malpractice lawsuit filed recently against SSM Health Care - St. Louis in Missouri and a neurosurgeon, and the plaintiff’s attorney suggests that the cause might be a failure of the entire operative team to participate in the time-out.

Regina Turner, 53, of St. Ann, MO, was scheduled on April 4 for a “left-sided craniotomy bypass” at St. Clare Health Center in Fenton, MO, according to a complaint filed in the Circuit Court of St. Louis County in Clayton, MO. Instead, she received a “right-sided craniotomy surgical procedure,” the suit alleges. (See the story on p. 76 for more details about the incident.)

The hospital issued statements confirming that the sentinel event occurred. A statement from Chris Howard, president and CEO of SSM Health Care – St. Louis, said the provider organizations “sincerely apologize for the wrong-site surgery in our operating room. This was a breakdown in our procedures, and it absolutely should not have happened. We apologized to the patient and continue to work with the patient and family to resolve this issue with fairness and compassion.”

The hospital immediately began an investigation and has taken steps to prevent such an error from happening again, the statement says. The hospital also confirmed that the neurosurgeon is an employee of SSM Health Care and has staff privileges at St. Mary’s Health Center and DePaul Health Center.

A review of the medical record and other investigation suggests that the error was not detected in time because not all members of the operative participated in the time-out, says Turner’s attorney Alvin Wolff Jr., JD, of Clayton. “That’s my understanding. For something like this to happen, shortcuts had to be made,” he says. “There’s just no way you follow the proper time-out procedures and have this result.”

Wolff is limited in discussing the Turner case because it is still in litigation, but he has handled other wrong-site surgery cases before and says a pattern has emerged. “The time-out procedures were not performed by the entire team,” he says. “You’ve got everyone there who is supposed to be the eyes and ears, looking out for each other and the patient, but some people think they don’t have to participate. The CRNAs may think that they don’t have to because they’re going to be behind the screen anyway, but the more people you have participating, the more eyes you have to see mistakes and prevent them.”

In one wrong-site knee surgery case, Wolff settled with the surgery center and the doctor but went to trial with the anesthesiologist and won an award for the plaintiff. “The anesthesiologist felt he didn’t need to participate in the time-out despite the universal standard,” he says.

Wolff attributes some of the problem to tort reform efforts in recent years.

“If you think you’re somewhat bulletproof, you’re not going to pay as much attention,” he says. “That’s the downside to tort reform.”


  • Alvin Wolff Jr., JD, Attorney, Clayton, MO. Telephone: (314) 241-2500.