When the operating room lights flicker on, most of us expect the steady hands of seasoned surgeons to guide us safely through. Yet, the unsettling reality is that “never events” – catastrophic mistakes that should never happen – still occur, with estimates of up to 80 such incidents each week in the United States, according to the American Medical News. The following 10 unimaginable 038 cases illustrate the most harrowing surgical errors ever recorded, each a stark reminder that even the best‑trained professionals can falter.
10 unimaginable 038: A Lesson in Surgical Oversight
10 A Man’s Worst Nightmare
In November 1999, 67‑year‑old Hurshell Ralls entered the Clinics of North Texas in Wichita Falls for a bladder‑cancer biopsy that confirmed a malignancy. The planned operation involved removing his bladder alone. When Ralls awoke, he discovered, to his absolute horror, that his penis and testicles had also vanished. The surgeons claimed that, during the bladder removal, they believed the cancer had spread to his genitalia, yet they never took tissue samples to verify this suspicion, deeming further testing “not worthwhile.” A Dallas pathologist later examined slides of the removed tissue and determined there was no penile cancer at all. Reconstructive options were impossible because insufficient tissue remained.
Despite the gravity of the mistake, the physicians faced no disciplinary action, and none of their medical licenses were suspended. Ralls pursued legal action against both the doctors and the clinic, ultimately reaching an out‑of‑court settlement for an undisclosed sum. No amount of money could ever replace the organs that were taken without his consent.
9 Wrong Infant
In 2016, newborn Nate Melton was delivered at University Medical Center in Lebanon, Tennessee. After a routine post‑delivery check, a nurse entered the parents’ room and delivered the shocking news: their baby had been mistakenly identified as another child and had undergone an unnecessary frenulectomy – a minor procedure that trims the tissue under the tongue to address tongue‑tie. The operating physician admitted the mix‑up, apologizing and assuring the family that the infant “barely cried” during the surgery. The Meltons announced their intention to sue the hospital once their son received a Social Security number, though the long‑term impact of the unnecessary procedure remains uncertain.
8 Wrong Limb
In 1995, 52‑year‑old Willie King was scheduled for a leg amputation at University Community Hospital in Tampa, Florida. While Dr. Ronaldo R. Sanchez was incising the tissue, a nurse reviewing King’s chart began to sob, prompting the surgeon to realize the catastrophic error: the wrong leg was being prepared for removal. By the time the mistake was recognized, the incorrect limb had already been sterilized and draped, leaving no chance to reverse the procedure.
Dr. Sanchez defended his actions by stating that both of King’s legs appeared diseased and that miscommunication among staff led him to believe he was operating on the correct side. Previously, another patient had claimed Dr. Sanchez removed a toe without consent during a foot‑tissue excision. Ultimately, Sanchez was fined $10,000 and his medical license was suspended for 140 days.
7 Four Years Of Pain
In 2007, 56‑year‑old Carol Critchfield underwent a routine hysterectomy and bladder‑support surgery at Simi Valley Hospital in California. Three days later, she returned with severe abdominal pain. An X‑ray was performed, and physicians dismissed her symptoms as extreme constipation, sending her home. The following year, while at work, she experienced sweating, blurred vision, and fainted, only to be told she suffered a gastrointestinal issue and advised to avoid spicy foods. These dismissals continued for years.
By 2011, Critchfield presented with vaginal bleeding, which doctors attributed to an ovarian cyst. During surgery to remove the ovaries, surgeons discovered a massive mass: a surgical sponge inadvertently left inside her abdomen during the 2007 operation. The sponge had become encased in scar tissue, leading to a four‑year intestinal obstruction that required removal of a large segment of her intestines. She sued Simi Valley Hospital and five physicians, reaching an undisclosed settlement in 2014.
6 Wrong Kidney
In 2013, a 76‑year‑old dialysis patient was taken to Mount Sinai Medical Center in New York for removal of a failing kidney. The surgeon, however, mistakenly excised the healthy kidney instead. Mount Sinai, a prestigious teaching institution, refused to disclose the identities of both the surgeon and the patient, and even barred news crews from filming outside the facility. Hospital officials blamed the mistake on the patient’s having “two bad kidneys,” a claim that did little to soothe the victim.
After the error became public, the surgeon was terminated, though the patient defended him, insisting the operation was otherwise successful. The patient subsequently underwent a corrective surgery to replace the removed kidney with the proper, failing one.
5 Neurosurgery
In 2013, 53‑year‑old Regina Turner was scheduled for a left‑brain craniotomy at St. Clare Health Center in St. Louis, Missouri. The surgeon, Dr. Armond Levy, performed the skull opening on the wrong side of her head. Upon realizing the mistake, Dr. Levy sutured the incision and arranged for the correct operation six days later, but the damage was already done.
Turner emerged with a severe speech impediment and required round‑the‑clock care. She sued both the hospital and Dr. Levy for negligence. The following year, she reached an undisclosed settlement, while Dr. Levy faced no state disciplinary action and continued practicing medicine, despite the grave error.
4 Wrong Patient
On November 20, 1998, 66‑year‑old Adesta L. Hytha went to Moffitt Cancer Center in Tampa, Florida, for a lumpectomy – a modest removal of a tumor and surrounding tissue from her left breast. After the procedure, she awoke to discover her entire left breast had been removed. Dr. Charles E. Cox, head of the breast‑cancer program, claimed he found additional cancer during surgery and felt compelled to perform a full mastectomy.
In reality, Hytha had been mistaken for another patient scheduled for a mastectomy. The truth was concealed from her for ten days, and Dr. Cox denied any wrongdoing. Hospital officials blamed the mix‑up on staff bringing the wrong patient into the OR and on Dr. Cox’s failure to review the chart. Hytha chose not to sue, settling for an undisclosed sum, and declined a hospital offer to reconstruct her breast.
3 Wrong Testicle
Veteran Benjamin Houghton was diagnosed with metastatic testicular cancer in 1989 and underwent chemotherapy, which successfully eliminated the disease. Over time, his left testicle atrophied, causing pain and the risk of cancer recurrence. In June 2006, he elected to have the painful left testicle removed at the West Los Angeles VA Medical Center.
During the procedure, the surgeon mistakenly excised the healthy right testicle. Houghton, his wife Monica, and their attorneys sued the VA for $200,000 in future health‑care costs plus undisclosed damages. Losing his functional testicle threatened his hormonal balance, potentially leading to depression, weight gain, fatigue, and osteoporosis due to a sudden drop in testosterone.
2 Wrong Eye
In 2015, one‑year‑old Fernando Jonathan Valdez from Ciudad Obregón, Sonora, Mexico, was battling advanced congenital cancer of his left eye. After chemotherapy failed, surgeons removed the diseased left eye. Tragically, the surgeon mistakenly extracted the healthy right eye, leaving the child permanently blind in the remaining eye while the cancer‑ridden left eye stayed in its socket.
The parents reported the mistake to police, prompting an internal investigation at the Medical Unit of High Specialty Mexican Social Security Institute. They hired an attorney, sued the hospital for negligence, and filed complaints with the National Commission of Human Rights and the Medical Arbitration Commission. The responsible surgeon was suspended and investigated, but regardless of the legal outcome, the boy will never regain sight.
1 Wrong Organ
In October 2011, 32‑year‑old Maria De Jesus, who was 21 weeks pregnant with her fourth child, went to Queen’s Hospital near London for an appendectomy. The operation was to be performed by trainee Dr. Yahya Al‑Abed under supervision of Dr. Babatunde Coker. Unfortunately, Dr. Coker was eating lunch and unaware the surgery was underway. During the procedure, De Jesus began bleeding heavily, and Dr. Al‑Abed, mistakenly believing he was removing the appendix, excised her ovary instead.
Three weeks later, still suffering from untreated appendicitis, De Jesus returned in excruciating pain. She underwent another surgery, but the delay proved fatal: she died on the operating table, and her unborn child was stillborn. Both surgeons were found guilty of “serious misconduct,” yet a tribunal later deemed them not a danger to the public, allowing them to continue practicing medicine.