When it comes to operating rooms, the phrase “never events” should be a clear warning sign – mistakes that simply must not happen. Yet the reality is far messier, and the top 10 disastrous slip‑ups listed below prove that even seasoned surgeons can get it spectacularly wrong.
10 Year-Old Gets Wrong Heart And Lungs During Transplant
In 2003, 17‑year‑old Jesica Santillan endured what many label the most catastrophic never‑event ever recorded. Three years earlier, her parents had smuggled her into the United States hoping for life‑saving treatment for her failing heart and lungs. Philanthropist Mack Mahoney, moved by her story, covered the costs for a transplant at Duke University Hospital.
On February 7, 2003, the operation began, but instead of compatible organs the surgical team used a donor set with the wrong blood type – the donor was type A while Jesica’s blood type was O, a lethal mismatch. Her body rejected the transplanted heart‑lung pair, triggering seizures and forcing her onto life support.
Two weeks later a second transplant was attempted with organs that matched her blood type. Although the new organs functioned, the damage from the first failed graft was irreversible – Jesica suffered permanent brain injury and remained on life support for a time before finally being weaned off.
At the moment of her death, roughly 200 patients across the U.S. were awaiting a heart‑lung transplant. Jesica’s case not only wasted two donor sets but also robbed other desperate patients of a chance at survival.
Why This Is a Top 10 Disastrous Case
9 Year-Old Woman Undergoes Heart Surgery For A Respiratory Infection
At Mediclinic Kimberley Hospital in Johannesburg, South Africa, an 83‑year‑old patient named Rita du Plessis was mistakenly taken to the operating theater for an invasive heart procedure that was meant for another individual. Rita had originally sought care for a respiratory infection.
Both Rita and the actual heart‑surgery candidate shared the same physician. When the surgeon received the order to bring the correct patient into the theatre, a name mix‑up occurred and Rita was wheeled in instead. After the operation, her family received a call announcing a successful heart surgery.
The error only came to light when the physician, still searching for the intended patient, realized the mix‑up and informed the staff. He later called Rita’s relatives to explain the blunder and offer an apology. The hospital did not bill Rita for the unnecessary procedure.
8 Woman Loses Breast To Cancer She Didn’t Have
In April 2015, 49‑year‑old Eduvigis Rodriguez underwent a mastectomy for what was believed to be an aggressive cancerous lump in her left breast. The surgery proceeded, and the breast was removed, only for post‑operative pathology to reveal that the tissue was benign – the lump was actually sclerosing adenosis, a non‑cancerous overgrowth.
The initial cancer diagnosis originated from a biopsy at Mount Sinai Beth Israel Hospital, after which Rodriguez was referred to Lenox Hill Hospital in Manhattan for definitive surgery. However, Lenox Hill staff failed to reconfirm the diagnosis, despite surgeon Dr. Magdi Bebawi signing paperwork indicating that such verification had taken place.
Following the unnecessary mastectomy, Rodriguez required reconstructive surgery. Court records later disclosed that she also suffered a surgical hernia and a pulmonary embolism as complications from the unwarranted procedure.
7 Wrong Patient Undergoes Brain Surgery
In 2018, Kenya’s Kenyatta National Hospital made headlines after a patient received brain surgery intended for a different individual. Both men arrived unconscious and were placed in the same ward, but a mislabeling of identification tags caused the wrong patient to be taken to the operating theater.
The intended surgery targeted a blood clot within the brain. Instead, the patient with a simple swollen head was brought in, and surgeons began the procedure. It wasn’t until two hours later, when they failed to locate a clot, that they realized the grave mistake.
The hospital responded by suspending the neurosurgeon, anesthetist, and two nurses involved. In a twist of fate, the patient who actually needed the clot‑removal surgery had improved on his own and no longer required the operation.
6 Elderly Woman Dies After Receiving Brain Surgery For A Jaw Displacement
Oakwood Hospital in Michigan found itself under intense scrutiny after 81‑year‑old Bimla Nayyar underwent an unnecessary brain operation. Nayyar had originally been admitted for a displaced jaw, a condition expected to be treated with a relatively straightforward procedure.
During her stay, a CT scan from another patient – showing bleeding in the brain – was mistakenly attributed to Nayyar. Believing she faced a life‑threatening intracranial hemorrhage, the medical team hurriedly scheduled emergency neurosurgery.
In the operating room, five burr holes were drilled into her skull before the right side was opened. Surgeons soon discovered no bleeding. The family was told of the error, but the gravity of the mistake was not fully disclosed. Nayyar never regained consciousness, remained on life support for 60 days, and was eventually taken off the ventilator on March 11, 2012. A lawsuit later awarded her family $21 million.
5 Doctor Amputates Wrong Leg During Surgery And Another Patient’s Toe Without Permission
In February 1995, Dr. Rolando R. Sanchez faced a courtroom drama after mistakenly amputating the healthy leg of 52‑year‑old Willie King, who was supposed to have his diseased leg removed. The error unfolded when a nurse, reviewing King’s file, burst into tears and alerted the surgeon that the wrong leg was pre‑pped for surgery.
Sanchez attempted to deflect blame, pointing to a faulty blackboard schedule, an erroneous operating‑room roster, and a mis‑entered computer record that all listed the incorrect limb. The leg had even been pre‑operated on before Sanchez’s arrival, adding to the confusion.
His medical license was suspended in July 1995 after a second blunder: he removed the toe of patient Mildred Shuler without her consent. Shuler had been undergoing foot surgery for diseased tissue when Sanchez claimed a bone “popped” and excised the toe to prevent infection.
4 Healthy Patient Loses A Healthy Kidney During Surgery He Didn’t Need
At St. Vincent Hospital in Worcester, Massachusetts, an unnamed patient walked out of surgery with only one kidney after being confused with another individual slated for a tumor‑removing nephrectomy. The real patient’s CT scan clearly indicated a malignant growth requiring removal.
Due to identical names, the healthy‑kidney patient was mistakenly wheeled into the operating theater. Post‑operative analysis revealed that the excised kidney was perfectly healthy, exposing a failure in patient‑identification protocols.
Hospital officials cited the name‑confusion and a lapse in age verification as the root cause, emphasizing that a more diligent check could have prevented the loss of a perfectly functional organ.
3 Day-Old Boy Mistakenly Gets A Frenulectomy
The University Medical Center in Lebanon, Tennessee, unintentionally performed a frenulectomy on a newborn named Nate, a procedure that trims the tissue connecting the tongue to the floor of the mouth. The surgery was meant for a different infant.
A nurse was dispatched to retrieve Nate for the operation, and his mother, Jennifer Melton, assumed the baby was being taken for a routine post‑natal check‑up. She only realized the mistake when the nurse began explaining the benefits of the tongue‑clipping surgery.
Jennifer, aware that her baby was healthy and didn’t need any oral surgery, questioned the identity of the infant handed to her. The nurse later confirmed the mix‑up, and the pediatrician admitted to operating on the wrong baby. An apology followed, but Jennifer pursued legal action.
2 Doctor Removes Woman’s Reproductive Organs Instead Of Appendix
In March 2015, an unnamed woman in the United Kingdom visited a hospital run by the Sheffield Teaching Hospitals Trust, complaining of abdominal pain. After tests indicated appendicitis, surgeons prepared to remove her appendix.
During the operation, however, the surgeon mistakenly excised an ovary and the adjacent fallopian tube. The doctor tried to downplay the incident, blaming poor vision and noting that the appendix and fallopian tube can appear similarly worm‑like.
This was the surgeon’s third major error in two years. In September 2013, he had removed fatty tissue from a patient who also required an appendectomy, leaving the patient in severe pain until a second surgery was performed. In another case, he removed a skin tag instead of a cyst. After these incidents, medical authorities banned him from treating further patients.
1 Doctor Removes Wrong Testicle During Surgery
In 2013, Steven Hanes was scheduled for a procedure at J.C. Blair Memorial Hospital in Pennsylvania to remove a painful, damaged right testicle. Instead, surgeon Dr. Valley Spencer Long mistakenly excised the left testicle.
Long claimed the mix‑up occurred because the patient’s testicles had somehow swapped positions. Hanes sued both the surgeon and the hospital, ultimately receiving an $870,000 settlement.