Orthopedic surgeon Edward Homan, who served eight years in the Florida House of Representatives, is the latest high-profile physician to be publicly embarrassed after operating on the wrong side of a patient.
Homan, who served as president of the Hillsborough County Medical Association and was chief of staff at a Tampa hospital for many years, must appear before the Florida Board of Medicine on Friday.
Half a dozen others are charged with wrong-side errors, which is about average for one of the bimonthly disciplinary hearings of the Board of Medicine. In all, about two dozen physicians will appear at Friday's meeting in Tampa on various charges.
The case involving Homan and the others before the Board did not involve a permanent injury, such as removing the wrong leg. The doctor, however, may have a permanent blemish on his license.
The Homan case involved arthroscopic surgery, a minor procedure to repair torn cartilage in the left knee. It took place in October 2013 at an outpatient surgery center on the Tampa campus of the University of South Florida.
Homan marked the correct knee before the patient, a 55-year-old man identified in the records only by the initials F.O., was taken to the operating room.
But somehow the circulating nurse, Brenda Bhatia RN, draped the right knee without checking for the mark, records show. And Homan too forgot to check for it.
According to the operative report, Homan didn't recognize he was in the wrong knee. He found a damaged meniscus in it and repaired it.
Investigators with the state Department of Health, who interviewed all of the people who had been in the operating room, never determined for sure what happened. They got conflicting accounts of whether the team took the proper "time out" to review the particulars of the operation to be performed.
Most said Bhatia read the consent form, which said the operation was for the left leg, out loud in front of at least three other members of the operating team. But no one noticed that the drape was on the wrong knee. Bhatia discovered the error later, when F.O. was in the recovery room.
Homan told investigators that when he found out what he had done, he felt as though he were going to faint. He told F.O. right away and apologized; F.O. agreed Homan should take him back to the operating room and repair the other knee.
Surgery center officials said F.O. did not have to pay for either operation.
Homan told DOH investigator Christopher Dickerson that he supposed he was "not thinking about what he was doing" and "did not have his mind in the game," records say.
Dickerson noted that Homan took responsibility for the error and did not try to make any excuses. That and his unmarred 47-year career led DOH prosecutors to suggest mild punishment -- a letter of concern, a fine of $1,000 and a requirement to give a lecture to other doctors about wrong-side surgery. It's up to the board whether to accept the proposed settlement.
Dr. Jeff Fabri, a patient-safety expert who spoke to Health News Florida several months ago on the topic of wrong-side surgery, said the best-trained, most-experienced surgeons are the ones who tend to make such errors. They think they are listening to the safety checklist but they've been through the motions so many times their minds wander, he said.
Health News Florida Special Correspondent Carol Gentry for WUSF in Tampa. Health News Florida, which receives support from the Corporation for Public Broadcasting.