Radiologist: Major error pre-surgery

AmeliaRose

My mother had surgery last week to remove breast cancer. First the radiologist put in the clip. My mom told her she already had a clip in that breast from 30 years ago. Radiologist told her that's why they had to put in a new one for this new spot. She then did the pre-surgical Needle-wire procedure. We left and went to surgical center and surgeon performed surgery. All went well and Dr said she got it out.

We've been waiting all week for results. Today Dr called and said THE RADIOLOGIST PUT THE NEEDLE IN THE WRONG CLIP!

She put the needle in the OLD clip from 30 years ago, and so that's where the surgeon did the removal. Except that is not the spot where the cancer is!

Dr is apologetic and said she's never seen this happen but that it's the radiologist's fault (who we were told "feels terrible about this").

So now my poor mom needs to go through this whole thing all over again. More waiting, more surgery, more waiting. I am livid of course.

Questions:

1. Is this uncommon?

2. Could waiting another week for surgery put my mom at risk for cancer spreading? (will now be one month since diagnosis)

3. Would you only blame radiologist?

4. My mom wants a new radiologist obviously to do second procedure but is wondering if she should use the same facility. The facility is the one her surgeon always uses.

Any advice would be helpful. Thank you.

gb2115

Wow, the radiologist probably does feel terrible! Nothing worse than making a genuine mistake that causes someone else pain.

How far apart were the two clips?

I wouldn't worry about a week delay. I remember my surgeon saying she doesn't get antsy until 6 weeks after diagnosis, and that's with the most aggressive tumors.

Emily2008

Oh, your poor Mom! What a mistake! And to think your mom even told the radiologist about the old clip. You'd think she would have been all the more aware of it.

To answer your questions:

1) I've never heard of someone making this mistake, but I'm sure it has happened. I had a friend who had a nightmare stereotactic biopsy due to a lousy radiologist. It was really traumatizing to her at the time.

2) A week is nothing to worry about.

3) I would only blame the radiologist. She's doing her procedure based on imaging and reports, so it's totally HER responsibility to know where to put the wire. The surgeon *may* be considered responsible to know which area to remove *if* there was enough of a positional difference in the breast. For example, if the current cancer is on the outer portion of the breast, but the radiologist put the clip on the inner portion of the breast, then the surgeon should have known, "Wait a minute, that's not the same place that we've been looking at." But, if the 2 areas are near each other, it would be really hard for a surgeon to notice a slight positional difference. That's why they rely on the radiologist to do the job right!

4) I would stick with the surgeon and the facility for two reasons. 1) It's not their fault, it was the radiologist's error, and 2) They will likely take EXTRA precautions and good care of your mom now that there's been this one screw up. They'll probably be more attentive and cautious to mitigate a lawsuit, which works in your mom's favor.

Best of luck!

whattodo123

I am so sorry to hear this happened to your mom. I have clip left behind my breast after the surgery now, since the surgeon couldn't find it from the tissue removed. I am shocked when saw the report. I was told by the radiologist placed the clip that this will be removed by surgeon. There should be a better way that radiologist and surgeon to work "together" without putting patients in the middle of all these.

AmeliaRose

thank you all for your kind words.

My mom had the second surgery a week after we got this horrible news about the mistake.

She decided it was her priority to GET BETTER as quickly as possible. She went back to the same radiology center but they assured her the woman who had worked with her previously will no longer be working with patients.

They didn't charge her for the second surgery. They had a car drive her there and back. They gave her lots of extra attention and no wait time.

The same surgeon performed the surgery. We just got excellent lab results. No radiation needed! No spread, no lymph nodes affected, great margins. We are thrilled.

Once she is up to it we will start talking to lawyers.

There absolutely MUST be inforced protocols in place between radiologists and surgeons, especially when they are working atdifferent facilities. This type of human error CAN be avoided. The more often they put clips in our breasts, the more everyone is vulnerable to mistakes like this.

molliefish

I'm curious to know what you hope to accomplish with a lawsuit?

wrenn

Puzzled by lawsuit as well but I am in Canada where that would be extremely rare.

Glad your mom had good results.

AmeliaRose

I'm not actually sure if we'll go down that road. We're more concerned with helping to make sure this doesn't happen again.

But itwas unnecessary surgery caused by human error.

MinusTwo

So - what does a law suit solve except to make money for lawyers on both sides?

Sounds like your radiology group has already taken care of removing the offending tech from the rota.

My grandpa at age 88 was hit by a car driven by a young women in labor trying to get to the hospital. Her husband was in the military over seas. My aunt & uncle wanted to sue. Why? No law suit would bring him back. The poor woman will live with the memory of hitting my grandpa every day of her life.

Wildplaces

AmeliaRose,

It is terrible that this happened.

And you are quite right in wanting to improve the system so less errors occur.

The hospitals have in place a whole review system for dealing with this from the individual to the team.

Without having the films it is very hard to know what/who exactly lead to this particular error.

What I can tell you is that unless you are seeking a financial settlement with a purpose in mind - ie to better your life in some specific way - the road through a lawsuit will cost you and your mother angst, time, money and many many sleepless nights. Please assess very carefully that impact - I am not saying let it go - that is for your Mum to decide - I am saying don't be fooled in thinking you will get something without a lot of stress to you because you won't ☺️

Wishing you both well.

ksusan

Another option is to file a complaint with the person's licensing board. This is not a financial move but does express concern to the certifying body, which will investigate as necessary. A complaint makes them aware of a potential problem, and for all you know, there are already complaints about this person and yours might be the one that triggers a response from the board.

AmeliaRose

that's really great to know, thank you. I'll tell my mom.

Kicks

I would also be discussing with the Surgeon, why hadn't he/she known that there were 2 different clips (one old/one new) that were supposed to be in different areas? Why he/she didn't varify the correct/new clip location which was supposed to be not be in the 'old' location before 'cutting'?

Seems to me that there was more than one 'mistake'. I'd be more upset with a Surgeon who did not varify/check before doing surgery.

Drs, be they Radiologists or Surgeons or any other Specialists, are after all HUMAN - not machines. Unfortunately, mistakes/accidents do happen, without any malace.

Reports do need to be filed so that the entire sititation can be reviewed and possibly better protochol be put in place. If a negligent pattern was a factor in case, then the Boards at the Facilities and the State/National governing Boards/Assoc. need to be advised.

SSBNewbie

I had a similar situation with my recent bilateral mastectomy. I had bilateral cancer with an IDC tumor on the left and ILC on the right. There was one biopsy marker clip on the right and 2 on the left.

During surgery, one of the clips wasn't removed. I didn't find out until 2 weeks after my surgery at my post op appointment. I had to have a second surgery to remove the clip. The clip had cancer cells around it, so 1 cm margins were removed around it. The surgeon said that there is a chance that the second surgery coukd cause blood flow problems with my flap and require ANOTHER additional surgery with my flap.

Beatmon

There definitely needs to be a new protocol put in place so that the same thing doesn't happen again

mauigirl62

Hello. I had something similar happen to me. When they did the biopsy to see if it was cancer they left a marker or clip so the surgeon would be able to find the cancer being that it was very small. The day of surgery the radiologist was supposed to put the wire through or on the clip but did not. He put the wire on breast tissue he thought was cancer. When the surgeon came in to talk to me before surgery he looked at the film of where the clip was placed and looked disturbed but did not say anything. While I was being put out for surgery he ran to talk to the radiologist. Not sure what happened there. This was supposed to be a easy surgery the only worry is whether it spread to my lymph glands. When I woke up I was told that my lymph glands were fine but he did not think he got the cancer. I noticed I had been in surgery twice as long as I was supposed to be. The biopsy came back normal breast tissue. So I had a second surgery with the wire placed in the correct place. My problem is now my breast looks different than the other. I would not care if that is what had to be done but they took normal breast tissue just because. Also they of course will not admit to a mistake. Even my gynecologist will not talk to me about it. She says to just forget about it. I am on a emotional rollercoaster. I feel extremely lucky to be ok. Just need to have radiation but am so upset that they could make such a horrible mistake. I am not sure what I should do. And who is at fault the radiologist clearly is but is the surgeon also for not having the wire replaced in the right place. Who can I call to look at my records to see who made the mistake?

MTwoman

the entire series of events should be reviewed by the proper licensing boards (see Kicks' post above). They should be able to pull all associated records, review the case and decide upon further action.