Thomas Shaknovsky botched the surgery of William Bryan, 70, who died on the operating table
According to Shaknovksy’s deposition, after removing Bryan’s liver, the surgeon instructed a nurse to label the organ as a “spleen” – and he also identified it as a spleen in Bryan’s postoperative notes. Shaknovsky later said he had been “mentally compromised” at the time of Bryan’s death, explaining that he was “devastated, demoralized, crying over his passing, felt that I failed him”.
Totally agree and this has been discussed a lot. We learn about the Swiss cheese model https://en.wikipedia.org/wiki/Swiss_cheese_model, I’ve read The Checklist Manifesto, we talk a lot in med school about listening to nurses and scrub techs and pharmacists…it goes on.
I’ve sat in on a lot of morbidity and mortality rounds. If there’s an adverse event it’s reviewed, and yes it can be very embarrassing for the people involved. We had a breast cancer patient who needed more exploration involving the axillary lymph nodes and an artery got nicked and vascular had to be called, and the next day she was bleeding significantly and had to be brought back to the OR with me, as the med student, holding pressure on her armpit. She lived. A few days later both attending surgeons (breast and vascular) had to do the Morbidity and Mortality in front of the whole hospital, and it felt like a movie.
This should be investigated exactly how you said but there is no way that surgeon was sober. Unless the patient’s anatomy was crazy weird, there’s no way that was an honest mistake.