Wrong surgery, wrong patient ID, wrong dosage

The big mistakes still happen, as evidenced by three recent events around the country in which doctors and hospitals had to explain major errors.

In Tampa, FL, Charles E. Cox, MD, the head of the Moffitt Cancer Center’s breast cancer program was fined $5,000 for removing a woman’s breast when he was supposed to remove only a tumor. The Florida Board of Medicine said its investigation determined that the doctor and operating room staff had confused her with another patient. The Board of Medicine ordered Cox to attend five hours of risk management classes and give a one-hour lecture to his colleagues about how the mistake happened and how it could have been avoided. However, the board did not issue a formal reprimand.

Cox told the board he had performed a left mastectomy on the wrong patient, a 66-year-old woman with cancer of the left breast, in November 1998. The woman was scheduled for a lumpectomy but she was brought into the operating room when Cox called for the next patient, a woman of similar age who also had cancer of the left breast but was scheduled for a mastectomy.

In a hearing before the board, Cox admitted that he failed to verify he had the right patient before starting the operation and did not learn of the error until he was almost finished. The incident happened three years ago but only recently came to light. Cox heads the Comprehensive Breast Cancer Program at Moffitt and is widely known and respected among cancer surgeons. He has performed 2,500 to 3,000 breast surgeries in the past 18 years.

In Washington, DC, a 9-month-old girl died at Children’s Hospital from a classic medication error: Hospital officials said a misplaced decimal point caused a nurse to administer a massive overdose of morphine. The child was supposed to receive two 0.5 mg doses of morphine, but she was given two doses of 5 mg each. According to information released by the hospital, the error was the result of sequential mistakes by the prescribing physician, a transcriptionist, and a nurse. The doctor wrote the prescription as "5 mg" instead of the preferred "0.5 mg."

The hospital reports that the nurse had 10 years experience. Even though the prescription was for 10 times the normal amount of morphine, she injected it without confirming the dosage with the doctor.

Another type of error occurred at Lakeland (FL) Regional Medical Center, where the staff mistakenly told a woman that her daughter had died in the hospital. According to statements released by Lakeland Regional, the hospital chaplain called Bridget Brantley at home to tell her that her 41-year-old daughter was dead. After driving to the hospital, Brantley was consoled by the chaplain for half an hour before a nurse told her there was a mistake.

It turned out that her daughter was alive. Another patient on the same nursing unit had died, and a nurse had given the wrong medical chart to the chaplain, according to a hospital spokeswoman. Both patients had undergone chest surgery, but the dead patient was an 81-year-old white man and Brantley’s daughter was a 41-year-old black woman. The hospital apologized, sent a basket of flowers, and informed Brantley’s daughter that she would not be charged for her stay.