In Portland, Oregon, a 25-year-old new mother already battling cancer for the second time went in for a procedure and her doctor made an error and performed a wrong site surgery. Sarah Christensen went into the hospital for removal of lymph nodes in her neck.

After surgery, the surgeon told her he had made a mistake. “He came in and he was kind of teary-eyed, and he just looked at me and said, ‘We need to talk,’ Christensen said. And he said, ‘I messed up, I read the report wrong. They reported it wrong, and you need more surgery.’ I just looked at him, and I cried, I was like, ‘I can’t take care of my baby as it is.'”

Sarah’s surgeon removed normal lymph nodes in the back of her neck. The ones that should have been removed were in the front of her neck. She did have surgery on the front of her neck at a later point, and cancer was found.

The couple is waiting for copies of Sarah’s medical records. From what she says, the doctor told her in one paragraph the cancer report told the surgeon to operate toward the back of the neck. But in another paragraph it said the cancer was in the front of her neck.

Christensen believes the doctor missed the discrepancy. “I should have asked to look at the report myself before the first surgery,” she said. “I come from a medical office background, so I feel like if I would have looked at it, I might have caught it.” Christensen said she wishes she insisted on a second opinion, which may have prevented a double dose of pain. “It’s hard to cope with everything that has happened,” she said.

Here are the key points that I see in this story and my take on the liability:

1. The checklist procedure the operating room staff go through to make sure they are operating on the correct side of the body may not have picked up this discrepancy. The surgeon incorrectly believed he should be operating on the back of the patient’s neck and would have scheduled the surgery that way. The operating room staff would have confirmed that back of the neck as the surgery site. It is unlikely they have liability.
2. The pathologist who completed the report that contained the discrepancy (front versus back of the neck) participated in the error. This person’s confusing results reporting may have contributed to the surgeon’s misinterpretation of the report.
3. The surgeon fulfilled his ethical obligation to inform the patient when he discovered the error. According to Sarah, he was upset by his realization of what he had done. The number of people affected by this mistake includes not only Sarah, her husband and infant but also the surgeon. But the surgeon misinterpretation of the results led to the operation in the wrong place.
4. Should Sarah have asked to look at her own medical records to confirm the correct location of the surgery? Should she blame herself for not doing so? Did she have any reason to believe the surgeon had misidentified the site? It is common for patients to look at their own involvement in an error and question what if anything should they have done differently. I am not so sure Sarah should hold herself accountable. She had reason to rely on the physician’s ability to interpret the medical test results. Would I advise every patient to review the pathology test results before surgery? It depends on the degree of concern or suspicion of a possible error. It also depends on the patient’s degree of understanding of medicine and the ability to read medical reports.
5. Wrong site surgery occurs at least 2 (according to the Joint Commission) to 6 (according to the Archives of Surgery Study) times a day in the U.S. This is one example of what can happen.

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The full story of Sarah Christensen’s wrong site cancer surgery is here.