Wrong eye operated on by mistake in a 4 year old

By Dr. Ananya Mandal, MDApr 19 2011

In a huge medical error, a four year old boy got the wrong eye operated by mistake.

Tasha Gaul, mother of 4-year-old Jesse said they had gone to a doctor today to find out if he suffered any permanent damage when a surgeon performed corrective surgery on the wrong eye and then, without consulting the boy's parents, quickly operated on the correct eye. “Right now we're in the dark about what this will be like in the future,” she said. The doctor they saw today told her they will have to wait 5 weeks for his eyes to completely heal before they can determine if there has been any permanent damage.

“No parent, no child, nobody should have to live through the torture of that day,” Gaul said. Jesse, of Vancouver, Wash., had been seeing Dr. Shawn Goodman in Lake Oswego, Ore., every six months since his parents had discovered he had a wandering right eye. Last Wednesday, a few days before his fourth birthday, he went into the operating room at Legacy Emanuel Medical Center in Portland, Ore. The doctor described the surgery as meant to weaken the muscle at the bottom Jesse's right eye, since the strength of that muscle was causing his eye to wander. It wasn't until she completed the procedure that she realized she had operated on the left eye.

“At 11a.m., the surgery should have been done and we should have been in the recovery room with our son at that point,” Gaul said. Instead, a nurse who was at the operating table came out and simply said, “We're operating on both eyes,” Gaul said. Before Jesse's parents could respond, the nurse had vanished. After the procedure on the right eye was finished, Goodman came out to address the family. Gaul said the doctor laid it out in medical terms. “I didn't understand at first,” said Gaul. “I asked, ‘Can you repeat that, because I'm not sure I heard correctly.’” Goodman then told the family that she had lost her sense of direction during the procedure because a nurse had mistakenly covered the mark Goodman had made on the eye that needed correction while prepping the boy for surgery.

Since the operation, Jesse's left eye seems to be wandering, while the right still does not seem fixed in the view of Jesse's mother. Fortunately, Jesse seems to have normal eyesight, but he is forced to put in eye drops three times a day, and must wear dark sunglasses to protect his eyes.

Neither Goodman nor the Legacy Emanuel Medical Center immediately responded but hospital CEO Dr. Lori Morgan said that procedures to help prevent mistakes like this failed. “We have a critical incident team that will be responding to it, that will be interviewing all of our staff in the operating room as well as private practice physicians in the operating room that were involved,” Morgan said, “Our hope is to never have it happen again in any of our hospitals.” Goodman is not a Legacy employee, but she was using their facilities to perform the operation on Jesse.

Parents of the boy said they have hired a lawyer and were considering a malpractice lawsuit. Gaul said she is concerned about the effects of the unnecessary surgery on her son's vision.