"It's serious, it's preventable, and it should never happen," said venerated patient safety advocate Dr. Kenneth Kizer upon hearing the story of young Jesse M.
The boy -- three years old at the time -- went in for a routine surgery to correct a "lazy eye." The surgery is simple and quick, and doesn't even require an overnight hospital stay. It all might have gone well, except that the little boy's surgeon operated on the wrong eye.
Studies estimate that wrong-site surgeries -- where the surgery is performed on the wrong body part or even the wrong patient -- happen as many as 2,700 times a year in the United States. That's about seven surgeries every day where a doctor cut into a person without verifying the patient's identity or medical problem.
In little Jesse's case, there was some initial confusion in the paperwork. On the morning of the procedure, a surgical nurse told them the paperwork was unclear about whether he needed the surgery on one eye or both. Although stricken with a sudden sense of dread, Jesse's mom went along with the plan.
The surgeon marked the correct eye and the correct incision site with a marker, seemingly following safety protocols. The surgeon now believes that one of the surgical nurses must have covered up those markings when prepping Jesse for the surgery. If so, the surgeon went ahead and operated despite not seeing the marks she had just made to indicate the correct surgical site.
After the surgery was over, the surgeon apparently told Jesse's mother, "Frankly, I lost my sense of direction, and by the time I realized it was the left eye, I was almost done."
Despite warnings, despite protocols, wrong-site surgeries happen again and again
Because of the shocking frequency of wrong-site surgeries, numerous patient safety groups have come up with checklists, protocols, and systems meant to prevent these "never events."
Dr. Kenneth Kizer is one of them. The former CEO of the safety advocacy group National Quality Forum, he is one of those credited with coining that term -- "never event" -- which is used in the patient safety field to describe one of 28 examples of medical malpractice that are simply inexcusable.
The first thought that went through Dr. Kizer's head when he heard about the wrong-site surgery on little Jesse M.? "Not another one."
While the rate of wrong-site surgeries has come down in the past decade or so, says Kizer, it's not enough. More needs to be done to convince doctors and hospitals that "never events" must actually never occur.
As for Jesse's mother, she has lost faith in the health care system even as Jesse awaits another surgery for the original problem and to correct any damage done to his previously good eye.
"With any surgery on your child, you're going to be stressed and worried and want to make sure it happens the way it's supposed to because you're there to protect them," she said. "I feel now I have to protect my child from these doctors no matter what. You really can't trust anybody."