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    Surgeon faces discipline for removing wrong breast

    The head of the breast clinic at Moffitt Cancer Center admits confusing two patients.


    © St. Petersburg Times,
    published June 1, 2001

    TAMPA -- A long day was ending, and Dr. Charles E. Cox, head of the breast clinic at Moffitt Cancer Center, had two patients left. One was to have her left breast removed. The other, a less radical lumpectomy to take out a tumor.

    As the operating room staff changed shifts, Cox asked for the next patient, the one scheduled for the mastectomy.

    She and Cox spoke briefly as she was prepped for surgery. After her left breast was anesthetized, he began to remove it. As he finished the operation, another surgeon came in and mentioned she had been speaking with a woman outside awaiting the mastectomy.

    "I said, "This is the patient,' " recalled Cox, a surgeon who has been nationally recognized for his work with breast cancer patients. "She said, "No it isn't.'

    "When I asked everybody, "Well, which patient are we operating on,' nobody in the room knew."

    For that mistake, which happened in November 1998, Cox faces disciplinary action from the Florida Board of Medicine today in Fort Lauderdale. He has signed an agreement with the state Agency for Health Care Administration calling for a $5,000 fine and a reprimand, but it needs board approval.

    The incident shows mistakes can occur even at medical centers ranked among the nation's best. An internal review at Moffitt said several people made several errors, including the staff members who brought the wrong patient into the operating room. But Cox acknowledged Thursday that the surgeon is ultimately responsible.

    Although he routinely checks patients' charts before operating, this patient's chart wasn't in the room, he said. He asked for it, but began before it arrived.

    Because of the error, Moffitt now requires every operation to begin with a nurse reading aloud the patient's name and the surgery to be performed.

    "There were a whole bunch of little systems glitches that occurred," Cox said. "I had spoken to everyone who was to be involved in that case and explained who needed to be put on the table, what procedure needed to be done.

    "I made a bad assumption, and one that I will never make again and shouldn't have made then."

    Cox is the program leader of the Comprehensive Breast Cancer Program at Moffitt, Florida's only National Cancer Institute-designated center. He said he has performed 2,500 to 3,000 breast surgeries in the past 18 years. This is his first disciplinary case.

    According to the complaint, the 66-year-old woman had been diagnosed with cancer of her left breast. She came to Moffitt Nov. 20, 1998, to have the tumor removed, a procedure called a lumpectomy. Instead, she was mistaken for a patient scheduled for a mastectomy, or breast removal, the agency says. The patient's name was not disclosed.

    "A reasonably prudent, similar physician under similar conditions and circumstances would not have performed surgery on a patient without properly identifying the patient," AHCA charged.

    Cox properly explained the error to the patient and reported it to the hospital and the state, the agency said.

    Cox's case comes to the Board of Medicine just as the board has begun cracking down on wrong and wrong-site surgeries, which have proliferated in recent years. Last year, the board heard 20 cases of wrong-site surgery or wrong procedures, compared with eight cases in 1999.

    This weekend alone, 11 other physicians are scheduled to be disciplined for wrong or wrong-site surgeries, including a Lakeland surgeon, Dr. Andrew Dobradin, who performed a hernia operation on the right side of a patient's groin when he should have operated on the left side.

    Such mistakes can occur when staff prepares the wrong site for surgery and the surgeon doesn't double-check, or the procedure is rushed.

    In an interview Thursday, Cox said several things contributed to the mistake, including confusion among operating room staff. Both women were to have their procedures under local anesthesia, which is unusual for a mastectomy, and the women were about the same age.

    The patient didn't sue, but the University of South Florida, which is affiliated with Moffitt, paid an undisclosed sum to settle the matter, a spokeswoman said. Moffitt also offered to reconstruct her breast, but the patient has declined so far, Cox said.

    Cox said he felt terrible about the mistake. For the past two years, he has been among a handful of area health care workers honored for patient care by the Healing Hands Community Partnership, a national consortium of medical societies and businesses.

    He also helped pioneer lymphatic mapping for breast cancer, a technique that helps determine how far cancer has spread through the lymph system. Doctors use it to determine precisely which lymph nodes must be removed, preventing the surgery and scarring of removing them all.

    "I feel chagrined that it all had to happen," Cox said of his mistake. "I'd like to put it behind me and move forward. . . . It's been pressing on my mind for three years."

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