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.
He told the Florida Board of Medicine on Friday that the error shook him to the core. “It’s like going through a divorce. It’s very painful,” he said. “It’s all you can think about for months.”
Homan, an orthopedic surgeon who specializes in joint repair and replacement, now works full-time at the James A. Haley VA Hospital in Tampa. The wrong-side case occurred in October 2013 at an outpatient surgery center at the University of South Florida.
His case was one of half a dozen Friday that involved errors of inattention, mostly wrong-side surgery or involving local anesthesia. Several board members expressed frustration that the problem keeps happening.
“We see it happening again and again,” said board member Dr. George Thomas. “We seem to be failing in this area.”
Dr. James Orr, who chaired a board committee addressing wrong-side errors two years ago, said the suggestions made at the time are clearly not working. He said that surgeons who do operations back to back all day – including orthopedists and ophthalmologists who do cataract operations – might be wise to schedule patients so that the focus is on one side or the other that day.
“Perhaps Tuesday should be the left day and Thursday should be the right day,” Orr said.
The chairman, Dr. Bernardo Fernandez, asked Orr to lead a new effort to address the wrong-side problem, and Orr agreed. Consumer member Brigitte Goersch, a former Air Force pilot, agreed to help.
None of the wrong-side cases that came up Friday at the board’s meeting in Tampa involved serious or permanent injury to the patients. In the past, however, such errors have included wrong-side amputations and even fatalities.
The Homan case involved arthroscopic surgery, a minor procedure to repair torn cartilage in the left knee. He 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. Homan admitted he too forgot to check for it.
He said he didn’t recognize that he was in the wrong knee because he found that the cartilage cushioning the knee – the meniscus – was damaged. He repaired it.
Four health professionals including Homan were in the operating room when the nurse read the consent form that noted the operation was to be on the left knee. Homan told the board he had no idea why none of them picked up on the fact that the wrong knee was draped.
Bhatia discovered the error later, when F.O. was in the recovery room. When Homan heard what happened, he told the board Friday, “I didn’t know whether to faint or just drop dead.”
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. The patient did not have to pay for either operation, records show.
Because Homan took responsibility for the error and has had no previous discipline in his 47-year career, DOH and the doctor agreed on a settlement of a letter of concern, a fine of $1,000 and a requirement to give a lecture to other doctors about wrong-side surgery.
Board member Dr. Steven Rosenberg tried to get the fine upped to $5,000, saying that is the usual amount imposed in a wrong-side case. But his motion failed, and the original settlement was accepted 10 to 2.
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.
