A case involving a Florida surgeon charged with manslaughter after allegedly removing the wrong organ puts a focus on surgical errors and accountability in healthcare.
While physicians and surgeons are at the center of these incidents, nurses are also critical in both preventing and responding to these events.
This case highlights system vulnerabilities, communication breakdowns, and ethical responsibilities that directly impact bedside practice. Understanding how surgical errors occur and how nursing practice can mitigate them is essential to protecting patient safety and maintaining professional standards.
What are surgical errors?
Surgical errors are preventable mistakes that occur before, during, or after a surgical procedure. These errors can lead to serious patient harm, including permanent injury or even death.
According to the Agency for Healthcare Research and Quality (AHRQ), some common types include:
- Wrong-site surgery (operating on the wrong body part)
- Wrong-procedure surgery
- Wrong-patient surgery
- Retained surgical items (e.g., sponges or instruments)
- Intraoperative injury to unintended organs
- Anesthesia-related errors
The case involving organ removal underscores one of the most severe forms: wrong-site surgery, which is rare but often catastrophic.
According to the AHRQ's Patient Safety Network, wrong-site surgeries are considered “never events,” meaning they are entirely preventable and should never occur in a healthcare setting. The Joint Commission considers these types of surgical errors, sentinel events, which are defined as “a patient safety event that results in death, permanent harm, or severe temporary harm.”
What happened in this case and why it matters
This case in Florida has brought renewed scrutiny to surgical errors. According to news reports, a surgeon was indicted by a grand jury for second-degree manslaughter after allegedly removing the wrong organ during a procedure in August 2024, leading to the patient’s death.
In this case, the patient was scheduled for a laparoscopic splenectomy. However, the surgeon reportedly misidentified the organ, allegedly removing the patient’s liver instead of their spleen, during surgery.
The error wasn’t recognized in time to prevent fatal complications. Authorities later determined that the mistake represented a significant deviation from accepted medical standards, ultimately resulting in criminal charges rather than solely civil malpractice action.
The outcome
While most surgical errors are handled through malpractice litigation, this incident escalated to criminal prosecution, with the surgeon facing manslaughter charges. This reflects a growing willingness in some jurisdictions to pursue criminal accountability when medical errors are legally deemed egregious or reckless.
The case of RaDonda Vaught, a nurse convicted following a fatal medication error in 2022, also brought national attention to how the legal system responds to serious medical mistakes.
This is a critical distinction. It highlights that:
- Not all errors are treated equally under the law.
- Severe deviations from standard care can result in criminal charges.
- Documentation, communication, and adherence to protocols are legally significant.
Why this case is relevant to nursing practice
Although the surgeon was the primary provider involved, cases like this are rarely the result of a single failure. They often involve multiple breakdowns in the system, including:
- Incomplete or unclear preoperative verification
- Failures in surgical time-out procedures
- Lack of team communication or failure to speak up
This case reinforces the importance of:
- Actively participating in surgical time-outs
- Verifying consent and procedure details thoroughly
- Escalating concerns immediately, even in hierarchical environments
It also serves as a reminder that nurses may be called upon to provide documentation or testimony in legal proceedings following a surgical error.
Why surgical errors still happen
Despite standardized safety protocols, surgical errors continue to occur due to a combination of human and system factors.
Communication breakdowns
Research shows that poor communication among surgical teams is a leading contributor to surgical errors. Misunderstandings during handoffs, unclear verbal orders, or failure to speak up can all increase risk.
Inadequate preoperative verification
Errors can originate before the patient even enters the OR. Missing or incorrect documentation, mislabeled imaging, or incomplete patient histories can set the stage for a wrong procedure.
The Universal Protocol, established by the Joint Commission, requires:
- Pre-procedure verification
- Site marking
- A “time-out” immediately before surgery
These steps help reduce the risk of surgical errors.
Hierarchy and culture
Healthcare hierarchy can discourage some staff from questioning surgeons or other providers. In high-pressure environments, this dynamic can lead to silence when concerns arise.
Research shows that psychological safety, where team members feel comfortable speaking up, is essential for enhanced team performance and preventing errors.
Fatigue and workload
Long shifts, staffing shortages, and high patient acuity can impair cognitive performance. Fatigue affects attention to detail, memory, and decision-making, all critical factors in surgical safety.
The nurse’s role in preventing surgical errors
Nurses are involved in every phase of surgical care: preoperative, intraoperative, and postoperative. Their vigilance can prevent errors before they reach the patient.
Preoperative phase
In the pre-op setting, nurses verify:
- Patient identity using two identifiers
- Surgical consent forms
- Procedure details and site
- Allergies and medical history
Any discrepancy must be addressed immediately. For example, if the consent form does not match the scheduled procedure, the surgery should not proceed.
Nurses ensure patients understand their procedure, which can serve as an additional safety check.
Intraoperative phase
During surgery, circulating nurses and scrub nurses maintain situational awareness and ensure adherence to safety protocols.
Responsibilities include:
- Participating in the surgical time-out
- Confirming correct patient, procedure, and site
- Tracking surgical instruments and sponges
- Monitoring for deviations from the planned procedure
If something unexpected occurs, such as a change in surgical plan, nurses must ensure that appropriate documentation and consent updates are completed.
Postoperative phase
After surgery, nurses monitor for complications that could indicate an intraoperative error, such as:
- Unexpected pain or swelling
- Signs of internal bleeding
- Organ dysfunction
- Infection
Early recognition and escalation can reduce harm and improve outcomes.
What happens when a surgical error occurs?
When a surgical error leads to serious harm or death, the consequences can be legal, professional, and emotional.
Legal implications
In severe cases, such as the Florida incident, providers may face criminal charges in addition to civil malpractice lawsuits and license suspension or revocation. Manslaughter charges are rare but reflect the gravity of preventable medical errors resulting in death.
For nurses, involvement in such cases can lead to:
- Board of nursing investigations
- License suspension or revocation
- Legal testimony or deposition requirements
Ethical responsibilities
Nurses are bound by ethical principles, including:
- Nonmaleficence (do no harm)
- Beneficence (act in the patient’s best interest)
- Accountability
When an error occurs, transparency is critical. Many institutions follow disclosure policies that require informing patients and families about adverse events.
Emotional impact on healthcare workers
Healthcare professionals involved in errors may often experience guilt, anxiety, and burnout, a phenomenon known as second victim syndrome.
Support systems, such as peer counseling and employee assistance programs, are essential for helping individuals cope and continue practicing safely.
Building a culture of safety in nursing practice
Preventing surgical errors demands a system-wide commitment to safety.
Standardization of protocols
Consistent use of checklists, such as the WHO Surgical Safety Checklist, has been proven to decrease complications and mortality.
Advocate for strict adherence to these tools, even in fast-paced environments.
Empowerment to speak up
Organizations must foster a culture where you feel empowered to question decisions.
Simple strategies can include:
- Encouraging open dialogue during time-outs
- Using structured communication tools like SBAR (Situation, Background, Assessment, Recommendation)
- Leadership support for reporting concerns
Ongoing education and training
Regular competency training helps you stay updated on best practices and emerging risks.
Simulation-based training can be particularly effective in preparing teams to respond to complex scenarios and potential errors.
Reporting and learning from errors
Incident reporting systems allow healthcare organizations to analyze errors and implement preventive measures.
Importantly, these systems should focus on learning rather than punishment, except in cases of gross negligence or intentional harm.
Conclusion
Cases like this one in Florida highlight that even experienced providers can make critical mistakes, making vigilance essential. Patient safety relies on a team approach, and nurses often serve as the final safeguard against surgical errors reaching the patient.
