Florida keeps public in the dark about serious medical mistakes

315 "wrong-site" incidents reported since 2012
Posted at 11:06 PM, Sep 29, 2016
and last updated 2016-09-30 09:19:16-04

“This is what I was afraid of reliving everything,” said an emotional Shannon Potts of Naples. The mom of three still lives with mother’s guilt.

Coleman Potts post-surgery
Coleman Potts post-surgery

"Maybe I should have gone with someone else and it wouldn’t have happened," she recently told the ABC Action News I-Team.

Six years ago, she agreed to let a then-Naples surgeon repair her son’s hernia. She would later learn the doctor also removed a portion of her 19-month old’s right testicle.

Judy Wood pre-surgery
Judy Wood pre-surgery

“I was in shock I think at first, like it was my fault because I chose the surgeon,” she said through tears.

68-year-old Judy Wood will likely never walk again after her attorneys claimed a Lakeland doctor improperly placed a stent in her main artery. A civil jury ultimately agreed. Her doctor, though, was never disciplined by the state for the incident.

"It doesn’t take much to make me cry anymore,” she recently told us.

Judy and Shannon’s son are among the rare but growing number of Florida patients who have fallen victim to so-called wrong-site procedures. These are medical mistakes considered among the most serious in Florida. Wrong-site procedures include medical procedures performed on the wrong side of patients, the wrong procedure done or even a procedure performed on the wrong patient. 

Wrong-site incidents are “never” events, meaning they should never occur

It’s estimated around the country, wrong-site incidents occur up to 40 times per week.

Dr. Jimmy Orr
Dr. Jimmy Orr

“It’s just totally unacceptable,” said Fort Myers Gynecological Oncologist Dr. Jimmy Orr. Orr is also a member of the Florida Board of Medicine, the governing body that disciplines Florida doctors who do wrong. This summer he made a public plea after the board slapped yet another doctor for a wrong-site procedure. In that case, the physician sliced open the wrong testicle of one of his patients.

 “The issues around wrong-site surgeries continue to plague this state,” Orr said to board members on June 3.

While most cases of wrong-site are relatively minor involving the wrong lens placed into a patient’s eye or the wrong knee prepped for surgery, others can be fatal.

In 2015, an Orlando doctor was slapped with a $30,000 fine for the 2013 wrong-site incident that ultimately killed an 11-year-old Orlando boy. The surgeon placed a mechanical implant in the wrong heart valve of his young patient. The young boy died five weeks later. The family would not comment on the case, their attorneys asked the Investigators not to mention the boy’s name. The case has been covered in the media.

Time out or no time out?

After a string of severe wrong-site incidents in the early 2000’s, including the amputation of a patient’s wrong leg in Tampa, the Board of Medicine adopted policies that require medical teams do a “time out” before they cut into a patient. In 2006, the board adjusted that policy to require doctors and their teams repeat the “time out” if any member of the team leaves the room before the incision is made.

In many wrong-site incidents that come before the board, the time out or pause rule did not occur. 

“I think patients have to be concerned about this, I think physicians have to be concerned about this,” said Dr. Orr.

Wrong site surgeries by the numbers

The Investigators found since 2012, Florida medical facilities have reported 315 wrong-site incidents to the Agency for Health Care Administration. The state agency tracks the numbers of “adverse” incidents in Florida.  Adverse incidents are medical incidents that can result in serious patient injuries. Wrong-site is considered an adverse incident.

This year, more than two dozen wrong-site incidents have already been reported. 16 licensed doctors have also been disciplined for wrong-site incidents this year. By year’s end, Orr expects the number of disciplined doctors to trump last year’s when 19 doctors were disciplined for wrong-site incidents. Cases are coming up constantly at board meetings which are held every two months.

“When you have 3, 4, 5, 6, 9, 10 wrong-site surgery cases [at a board meeting], you just say to yourself how does this continue to happen,” he said. “We have a problem."

It’s a statewide problem, the ABC Action News I-Team discovered Florida keeps the public, largely, in the dark about.

About one third of incidents reported since 2012 resulted in doctor discipline. While there can be significant lag time between the date the incident occurred and the date of discipline, unless a doctor is punished for a wrong-site incident, the public will not have any access to even basic details. No punishment means no public record.


This exclusive interactive map highlights licensed Florida doctors who have been disciplined for wrong-site, wrong-procedure or wrong-patient surgeries since 2012.  These surgeries occur when a doctor performs a different procedure on a patient than what that patient consented to.  Since 2012, Florida medical centers have reported 315 wrong-site incidents.  However, the number incidents that resulted in doctor discipline is far fewer.  According to data from the Florida Board of Medicine and FL’s Agency for Health Care Administration, of the 315 wrong-site incidents reported to the state since 2012 doctors received discipline in approximately 1 out of 3 incidents.

Find out where wrong-site incidents have lead to doctor discipline in Florida. Select a medical facility or click on the blue markers to learn more the incidents and the doctor(s) involved.

The public’s right to know?

“Shouldn’t the public know more about these,” Investigator Katie LaGrone asked Dr. Jay Wolfson, a medical ethicist and doctor at the University of South Florida.

"We as consumers have a right to know what the failure rates are,” he said. “When those events happen it’s important for all of us to know. It will help us become part of an informed, activity community rather than wondering what's going to happen next," he said.

The Investigators found states like Washington, Minnesota and Texas allows consumers to search where wrong-site incidents occurred by facility. Florida posts just a quarterly number of incidents on a website run by the Agency for Health Care Administration (AHCA).

According to AHCA, wrong-site reports are “confidential under Florida Statutes.”

Looking right ahead at wrong-site

Judy and her husband have adjusted to their new reality.

Judy Wood post-surgery
Judy Wood post-surgery

Shannon Potts’ son is now 9 and thriving.

“I just don’t want him to think he’s different than any other child,” she said.

But the future remains unknown for these families and this statewide problem some say, is barreling down the wrong side of right.

“It’s not going to go away from our standpoint, we’re not going to say this is ok,” said Dr. Orr.

Reducing incidents of wrongs-site procedures is so top of mind right now, the state medical board has created a special sub-committee to focus on solving this problem.

Unless lawmakers change the law, basic details like when and where wrong-site surgeries in Florida occur will largely remain secret.

Don't become a wrong-site victim

  • Make sure you’ve been given a patient identifier- a wrist band
  • Check the info on your wrist band to ensure its correct
  • Speak up if you have concerns or questions.  If you still don’t understand, ask again
  • Pay attention to the care you get.  Make sure you are getting correct treatments, don’t assume anything.
  • Educate yourself about your illness. Learn about medical tests you get and treatment plan
  • Ask a trusted family member or friend to be your advocate.
  • Know what meds you take and why you taken them.  Medicine errors are the most common mistakes.
  • Use a hospital, clinic, surgery center that has been carefully checked out.  
  • Participate in all decisions about your treatment.

Source: Joint Commission, an independent non-profit organization that accredits health care facilities