Woman Scheduled for Back Surgery Leaves Operating Room Without Kidney
Maureen Pacheco arrived at Wellington Regional Medical Center’s operating room on April 26, 2016, hoping to have back surgery to alleviate pain she had been experiencing after a car accident. She left the center without one of her kidneys. The physician responsible for the mix-up had mistaken the healthy organ for a cancerous tumor and had removed the kidney while Pacheco was under anesthesia. She never had a chance to consent, and later filed a lawsuit, which was settled in September.
The surgeon who called for Pacheco’s kidney to be removed in the operating room wasn’t even the one who was scheduled to perform the back surgery that day. Pacheco met Dr. Ramon Vazquez shortly before being directed to the operating room. His job was to make the initial incision so orthopedic surgeons could perform the operation.
During this time, Vazquez made a “presumptive diagnosis” when he noticed what he thought was a malignant pelvic mass. He removed the organ and a month later a pathologist at Wellington Regional confirmed the mass removed was actually an intact pelvic kidney.
“As you can imagine, when someone goes in for a back surgery, she would never expect to wake up and be told when she’s just waking up from anesthesia, that one of her kidney’s has been unnecessarily removed,” said Pacheco’s attorney, Donald J. Ward.
Florida’s Department of Health has followed up with an administrative complaint against Vazquez, and the doctor could face penalties, including paying a fine or even losing his license. He has served as chairman of surgery at Palm Beach Gardens Medical Center since January 2018 and has privileges at several locations, including St. Mary’s and Good Samaritan medical centers as well as Bethesda Memorial Hospital.
“Few medical errors are as vivid and terrifying as those that involve patients who have undergone surgery on the wrong body part,” according to the federal Agency for Healthcare Research and Quality, which calls such errors “never events,” and the agency has found that they only occur in about 1 of 112,000 surgeries.
“The case was settled on his behalf for a nominal amount due to the uncertainty of litigation and in no way did Dr. Vazquez admit liability by agreeing to this settlement,” Vazquez’s attorney Mark Mittelmark said. The malpractice insurers for Pacheco’s primary surgeons, Dr. John Britt and Dr. Jeffrey Kugler, settled for $250,000 each. Prior to the malpractice claim filed by Pacheco, Vazquez had no record of disciplinary action.
The Health Department complaint alleged the cancer diagnosis was not related to the patient’s medical condition and “therefore medically unnecessary.” Two MRIs performed prior to surgery showed the kidney in Pacheco’s pelvic region, yet Vazquez failed to review them and never got Pacheco’s consent to remove what he thought was a cancerous mass.
In a response to the malpractice lawsuit, Vazquez’s attorney placed blame on Wellington Regional for failing to inform him that the patient had a pelvic kidney. The lawsuit filed by Pacheco offers only vague, non-specific details about the consequences of having lost one of her kidneys.