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Swedish hospital performed eye surgery on wrong woman

TT/David Landes · 6 Oct 2009, 10:29

Published: 06 Oct 2009 10:29 GMT+02:00

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“No one checked to make sure it was the right patient,” said chief physician Lars-Göran Holtby to the Arbetarbladet newspaper.

The woman was at the hospital in Gävle in eastern Sweden last summer after having cataract surgery on one of her eyes. Doctors scheduled the follow up to see if she might need surgery on her other eye.

But a series of oversights by hospital staff, combined with the woman’s impaired hearing, resulted in the 70-year-old going under the knife instead.

Upon coming to the hospital, the woman mistakenly believed she was set to have another operation, so when the nurse came to the waiting room and called a similar sounding name, the 70-year-old promptly stood up and followed the nurse into the operating room.

As she was being prepped for surgery, doctors told the woman she was going to have surgery on one of her eyelids. Since one of her eyelids was a little saggy, the 70-year-old was happy to go ahead with the operation.

But no one bothered to check the woman’s identity before the operation took place.

It was only later, when someone at the eye clinic reception made inquiries as to the woman’s whereabouts, that the mistake was discovered.

“That just can’t happen. In this case, there was no harm to the patient, but it’s potentially quite dangerous when patients are mixed up,” said Holtby.

Story continues below…

Despite the mix up, the 70-year-old reports that she is satisfied with the operation.

Nevertheless, the incident has been reported to Sweden’s National Board of Health and Welfare (Socialstyrelsen).

TT/David Landes (news@thelocal.se)

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Your comments about this article

11:08 October 6, 2009 by benomax
What a stupid mistake, what is happening to the health department of late? I hope they do not cut off someone's manhood by mistake or kill someone by mistake soon.
11:18 October 6, 2009 by Rick Methven
"it's potentially quite dangerous when patients are mixed up," said Holtby."

What an understatement!!
11:34 October 6, 2009 by DamnImmigrant
Benomax, medical mistakes happen all the time. Surgical mistakes are the worse kind and yet they still occur. The WORLD WIDE medical establishment is doing everything they can to try to figure out how to avoid these kinds of errors but nothing is foolproof. What is interesting to me is that there are a lot more of these kinds of errors in the American healthcare system than there is outside of the US. One solution they came up with was to use magic marker to write something like, "Do NOT remove this leg" on one leg and they write "Remove this leg" on the other!!!

This incident sounds like a Monty Python skit. It sounds like they did things right. They called a name and 1 person gets up. They explain what they were going to do and the patient says OK. I wondered if it is a little Alzheimers going on here.

I suppose the only thing that can be done to avoid these kinds of mistakes is to have RECEPTION write on EACH patient's hand what procedure they are there for.
12:01 October 6, 2009 by Rick Methven
Whenever I go to the hospital or Vardcentral to have any proceedure done, I have always been asked to confirm my personnummer before anything is done.
12:30 October 6, 2009 by DamnImmigrant
Rick - RIght!!!! (Pink Floyd?, get it?)

Yup, after your statement, I realized you were absolutely correct. Same thing for me too!

So in this case procedure was not followed - unless verifying the person number is not SOP (Standard Operating Procedure).
12:47 October 6, 2009 by krrodman
Let's be clear about this; this elderly woman was assaulted with a knife. The fact that everything turned out OK is just dumb luck.

Let's start with the basics:

1. Did anyone check the name band on the patient to make sure it corresponded to the name of the patient scheduled for surgery?

2. Was there a surgical consent?

3. Did anyone ask the patient "Why are you here today?"

4. Was there a surgical chart?

5. Did the surgeon not recognize his own patient?

Damnimmigrant refers to a case in the US in which a patient had the wrong leg removed. That case is more complicated than presented in the press. In fact both of his legs were horribly diseased. I do not excuse the actions of the surgeons, but is was not a case of a surgeon removing a healthy leg while leaving a diseased leg on the patient.

This case is MUCH WORSE. The surgeon operated on the wrong patient!!!! In the US that would be a case of criminal assault. The fact that she may have dementia makes it worse. Aren't we supposed to take care of those who are not capable of taking care of themselves?

In the US today no surgical case starts without a "timeout" in which every member of the surgical team including doctors and nurses stop to review the basics of the case: confirm the name of the patient; review the surgical consent; confirm the site of the surgery; review the pertinent medical history such as allergies.

The medical system in the US has its flaws. In this regard we are light years ahead of Sweden.
13:35 October 6, 2009 by Beynch
Would it be possible to find out what medical school the inferior, responsible, quack graduated from? Or would this be inseeeeensitive, or discriiiiminating?
14:45 October 6, 2009 by Rick Methven

I think that checking the Personnummer is standard practice. 4 years ago, I broke my hip. When I was wheeled into the operating theater to have the break pinned, I was asked to repeat my PN which was checked by the surgeon against that on a wrist band. This was despite me being rather high from the pre-med!

Last month I went to the Hospital eye clinic for a test. My name was called out by a nurse, who tokk me to the doctors room. He then also asked me to repeat my PN. So I am sure that the checks are standard

(the above incidents happened at 2 different hospitals)
14:58 October 6, 2009 by DamnImmigrant
@krrodman - "The medical system in the US has its flaws. In this regard we are light years ahead of Sweden."

LOLROTFL!!!!!! (In this regard) - The USA is LIGHT YEARS ahead of Sweden in it's medical FLAWS!!! -- Oh soo true! You have NO idea how true your statement is!

krrodman, You really need to get out more, you seem young and idealistic; unfortunately reality is going to be real painful when it finally catches up with you! You are living in a dream world with your "surgical timeout" ideals! I've been there, never seen it, though I do not doubt it MUST become the norm!!! To further destroy your dream world, IN THE USA, when surgeon operates on the wrong patient ... it is NOT "a case of criminal assault". Happens more frequently than anyone cares to admit! Been there, done that, NO Criminal trial!!!!

krrodman! You really need to read between the lines and not put words in someones mouth!! Again, you REALLY need to get out a lot more -

I, the DAMNIMMIGRANT, WAS NOT referring to ONE CASE in particular!!! I am referring to the state of medicine the world over!!!

I am referring to the incredible number of times in the US where a patient would wake up to find that they were missing something that should NOT have been missing because the DOCTOR operated on the WRONG patient!!! No criminal trial!!! (dreamworld)

I am referring to the NUMBER of times that the CORRECT patient wakes up to find the WRONG part was removed!!! Again, no assault charges!

I am referring to cases where INDEED the PERFECTLY HEALTHY leg was removed instead of the diseased leg!!! I am referring to the patient who wakes up to find their ONE GOOD kidney was mistakenly removed while the diseased kidney still needs to come out!!!

TRAGIC, STUPID errors that happen ALL OVER THE WORLD!! So the hospitals started using MAGIC MARKER to physically MARK what needed to be removed and what did NOT!!!

krrodman, it looks like you do not know the Swedish medical system, which is VASTLY superior to the American system. In America, the Swedish System would be called an HMO on steroids! I speak from EXPERIENCE (40+ years there, 10 years here!), while you probably speak from patriotism.

1. Did anyone check the name band on the patient ... There is no name band, think of it as a walk in outpatient surgery. There is the ID number which should have been checked but was NOT checked!

EDIT - Actually, I think you might get a name band if you will be unconscious during the surgery.

2. Was there a surgical consent... If you read the article, you would see that she LIKED the idea of getting her lids worked on. So yes! She gave concent B4 surgery!

3. Did anyone ask the patient "Why are you here today?"... To have my eyes worked on! The problem is being specific. The Doctor told her what he was going to do. She should have stopped it!

4. Was there a surgical chart?... Chart? What would that do? Has the chart got her picture? Even then, hey, they all look alike to me.

5. Did the surgeon not recognize his own patient? Never met them B4, remember out patient surgery.

krrodman, my point was that no matter how perfect someone thinks their medical system is, that mistakes STILL happen and we SHOULD learn from our mistakes! My point was also that STATISTICALLY the US has a higher incident of "MISTAKEN" surgeries than Sweden, or even the rest of EUROPE!!!
16:41 October 6, 2009 by sherkovic
@damn; do you think anyone has time to read what you just wrote?
16:47 October 6, 2009 by krrodman
Comment: Wow... Where to begin. I am not a "young idealist" as you mention. I have been practicing medicine for 30 years and at the present time I manage an operating room that performs 8000 cases per year. I am not an apologist for American medicine. There are many things that we do poorly as well as many things that we do well. That was not my point. Rather, my point is that we have directly addressed the issue of wrong site surgery with a series of processes that have dramatically reduced the incidence of wrong site/wrong person surgery.

It is clear to me from this article that Sweden has yet to introduce these processes. Let me address your points individually.

1. You indicate that there is no armband because it is outpatient surgery. Obviously, that is a huge problem. Patients can be placed into the wrong operating room and then once they are sedated(there is sedation in outpatient surgery) they can no longer be relied on to answer any question accurately. That is why the patient must be identified immediately prior to starting an operation.

2. Surgical consent. You indicate that she consented to surgery because she "liked" the idea of having her eyes operated on. Sorry. A consent is a written approval of a procedure in which the patient is informed of the risks and benefits of a procedure. There was no consent for this surgery.

3. You suggest that it was the responsibility of the patient to stop the surgery. That is silly beyond words. The professionals who are supposed to take care of her failed her completely.

4. The surgical chart is essential here. It will contain all of the pertinent medical history including the most basic facts such as name,age, height and weight. If the surgeon had reviewed the medical record before operating he might have realized that the patient in the medical record did not match the patient on the operating room table.

5. How is it possible that a patient never meets the surgeon prior to surgery? Sounds like an assembly line at the Volvo factory. Are you telling me that in Sweden the surgeon doesn't even introduce himself to the patient prior to surgery? Or let me ask the question differently. Do you think the mistake may never have occurred if the surgeon spent 2 minutes with this patient prior to surgery? How about this: " Good morning Mrs. Svensson, my name is Dr. Bergman. I am going to be your surgeon today." 'I am sorry, did I hear you correctly? Your name is not Svensson but Andersson?! There must be some confusion here."

It is clear to me that despite your yelling and screaming, you have very little direct knowledge of medical practice in the US in 2009. But, US medicine is not on trial here. I am surprised that you are defending a Swedish system that completely failed an elderly patient. The sad fact is that unless this hospital in Gavle changes its identification processes the very same mistake will happen again.
18:58 October 6, 2009 by DamnImmigrant
krrodman, I am not a medical doctor so I am NOT the best source for information for how things are done here. You really need to contact the medical authorities and ask them. Some of the other forum members have already pointed out that PROPER procedures were NOT followed in this case! Since we have fewer "mistakes" here than you do there, I have to assume we have similar/better? procedures here - as long as they are followed!

It is true that I have not experienced first hand the US medical practice in 2009 but I have seen no laws mandating changes across the US. I do my best to stay current as to what is happening. That is why I believe that the surgical timeout is a great idea that SHOULD be practiced! Are you saying it is the LAW that is now practiced at all hospitals across the US? This should help cut down on medical mistakes but I have seen nothing coming out of the US to indicate this is happening. The last statistic I saw said the US was still one of the leaders in medical mistakes. The question posed is why are there so many more mistakes in the US system. It is not saying that the US system is bad, it is asking, what is failing there?

I am blaming NO ONE! I am looking for answers that help to fix the problem. To say that this kind of stuff happens because the the WHOLE system is broken, ignores the fact that it happens everywhere. To take an incident that occurs because proper procedures were not followed and then infer that the whole of the system is broken is absolutely WRONG!

I really wish I could believe you manage an operating room with over 8000 operations per year. Unfortunately, denying any knowledge of medical mistakes and talking about the "1 time" such a thing happened, causes me to doubt your validity. You sounded like a young person! I realize that every hospital is different. I can understand if you are making the claim that your hospital has a 100 percent safety record for never doing surgical mistakes, but this is not true across the USA or even the world! I would be very interested to know more about what you are doing different.

The other fact (that also made you sound young) was when you referred to operating on the wrong patient "In the US that would be a case of criminal assault." causes me to doubt your claim as well because you would know for a FACT that these things happen and the doctors are not charged (at least that I can recollect). Maybe somewhere in some city some doctor was charged by the prosecutors office but I have NEVER heard of it. Very rare IF at all.

Yes, I have experienced the medical system in the US and here in Sweden. You, the medical professional, WOULD believe the medical/surgical mistakes that I have personally experienced in the US. I learned very early in life to question the doctors actions and motives.

That said, I will definitely defend the Swedish system because it works! What is even better here is that I trust the doctors here more because the profit motive has been largely curtailed. Do not get me wrong, I am NOT defending the mistake that was made to this woman and I am more curious as to why it occurred. We have a great medical system here, but that does NOT mean it is perfect.

By the way, I believe it costs about $3,500 per year per person and you would not believe what is covered and how much is covered! If you were to buy this coverage in the US, it would be over $2,000 per month! Which means the system here is VERY efficient!

I would invite you to come to Sweden to check it out.

If you are a medical professional, my profile should answer some of your questions as to my motivations. Sorry if I though you were a US Medical bigot.

OH, By the way, I think I figured out where you went wrong when you said; "It is clear to me from this article that Sweden has yet to introduce these processes." The real problem with this news website "thelocal.se" is that it has a bad reputation for incomplete or even missing facts. (It seems like the reporter are paid by the word, so news articles are kept very short which means you leave important stuff out.) It is so must better to leave out the IMPORTANT information so that instead of the story becoming balanced and factual, it becomes SENSATIONALIZED!!!!
19:45 October 6, 2009 by krrodman

Now we can have a positive talk. I do manage an operating room with 8000 cases per year. I never said, or meant to imply, that we never make mistakes. I do believe that we have made changes that have reduced the incidence of medical errors.

Let me tell you a little more about myself. I have been married to a Swedish citizen for 28 years and we own a small cottage in Osterlen. My in-laws still live in Hassleholm. I have published articles on the differences between medicine in the USA and in Sweden. As you are well aware, they are very very different.

The advantages of the Swedish system is obvious to all of us. There is universal coverage at a very modest cost when compared to the USA. That is a wonderful thing.

But, there are problems, primarily related to rationing of care. Let me give you two examples. Just to be completely forthcoming, the examples below apply to all countries with socialized medicine, Sweden included.

1. The average age of a dialysis patient is 6 years older in the USA and the average duration of dialysis is 6 years longer in the USA than in countries with socialized medicine. Dialysis is a very expensive therapy and requires continuous medical intervention in order to keep dialysis patients alive. Care for the dialysis patient is extraordinarily expensive. The USA is willing to spend unlimited sums of money on a dialysis patient. It is well recognized that European countries will not commit those kinds of financial resources to sick, elderly patients.

2. The wait time for surgery is longer in countries with socialized medicine. While this is not usually a problem, at times it is deadly. For example, the time from diagnosis of severe heart disease to coronary bypass surgery is longer in countries with socialized medicine than in the USA. The result of this wait is that more patients have heart attacks while waiting for surgery in countries with socialized medicine than in the USA.

Bottom line: There are approximately 30 million US citizen without health insurance. Horrible. Simply horrible. That said, I would rather be an elderly patient in the USA than in Sweden. In the USA the medicare program(socialized medicine for the elderly) will spend unlimited sums of money on any and all care, far beyond what the Swedish system is willing to spend on the elderly.
23:23 October 6, 2009 by KBIS26
hehehehheeheh . what kind of Doctor is he ?!!! if he don't remember his patients face ? come on are you kidding with me or what ?! how many patients he see in a day 5 or 10 in 8 hours !!!!!!!! or may be we should thank God and the Doctor also for his kindness as he didn't operate him for some kind of retinal implantation hehehehehe
08:13 October 7, 2009 by RandyLP
Here in the US most hospitals have implemented a rather involved "time out" procedure before an operation in which everybody in the operating rooms stops what they are doing and confirms that the correct surgery is being done on the correct person. In fact, the main hospital accrediting organization in the states (JCAHO) requires it. There still is the opportunity to screw up, but the chances of that happening are much smaller. My guess is that Sweden will start doing this pretty soon too.
15:01 October 7, 2009 by Beynch
Jeez. Some of you are writing much to long. It's like epic doctorates, or a speach by Comrade Fidel. If you can't say what you have to say in 7 lines or less, don't say it! Most of us don't have the stamina to read these seemingly endless diatribes. Shorter commentaries! Please!
16:39 October 13, 2009 by NJGirl
Krrodman, thank you very much for your very informative and objective comparison of Swedish and American healthcare system. Quite frankly I am speechless that they are people who still think that socialized medicine is superior to American healthcare. I can not imagine similar mistake that happened to this poor woman happening in USA. I recently underwent a major surgery and I personally met ALL the doctors involved in my care. They ALL personally explained to me what each of them would be doing so I can sign a consent. Most important of all, my wrist band has been scanned every time someone needed to check my identity ant that included giving all medication. This system if implemented in Sweden would eliminate mistake in this poor, hard of hearing Alzheimers patient. I do agree, after reading similar articles about Swedish medicine that Sweden indeed is light years behind USA.

PS Swedes! - you get what you pay for and it is a shame!!!
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