Surgeons Remove Wrong Side of Child’s Skull

Surgeons at Children’s Hospital of Orange County mistakenly removed the wrong side of a child’s skull during a brain tumor operation in January after failing to follow proper procedures leading up to the surgery, according to a state report.

Doctors realized their error when they saw no tumor under the left-side portion of the skull they removed. They then correctly performed the operation on the right side of the patient’s head.

The wrongly removed portion of the skull was replaced during the same surgery, and the patient did not suffer complications as a result of the mistake, said Dr. James Cappon, CHOC’s patient safety officer. He said it was the first time for the hospital that a so-called “wrong site surgery” had occurred.

A CHOC spokeswoman said the patient’s family had asked the hospital not to release any details about the child. The spokeswoman, Denise Almazan, said the parents had kept their child under CHOC’s care.

The report, by the state Department of Health Services, said operating staff failed to mark the spot on the child’s head where the procedure was supposed to be performed and did not take a required “time out” before starting the operation to use patient records to verify that they were operating on the correct site.

The doctors also failed to document in the patient’s medical records that the wrong-site surgery had occurred. However, the hospital did notify the state, triggering the investigation.

The report said the mistake may have occurred because a doctor moved the operating table to make room for an assistant surgeon, disorienting the staff. The patient was under the care of CHOC doctors, but the incident occurred across the street at St. Joseph Hospital, where CHOC contracts for operating space.

CHOC, in the city of Orange, would not release any information about the physicians involved.

Cappon said doctors at the hospital were reviewing the incident. He said he could not comment on what action, if any, might be taken against the doctors.

Details of the report were first published Tuesday by the Orange County Register. The hospital has until April 17 to submit a “plan of correction” documenting changes it will make to prevent a recurrence.