In June 2007, an 83-year-old man went to the Northwest Medical Center in Margate to have his inflamed gallbladder removed. The surgeon took out the man's kidney instead. Dr. Bernard Zaragoza told the Florida Medical Board that he was "completely mortified" by his error, and that's about the reaction you'd also expect from his patient, identified only as J.C.
According to an article in Health News Florida, J.C. died three weeks after the operation, though from heart failure that may have been unrelated to the surgical snafu. In the two years since, the state medical board has been divided about how to punish Zaragoza.
The board has found that in Florida, there's a "wrong-side surgery" roughly once out of every 100,000. Zaragoza might have seemed an unlikely candidate to commit one. He has a degree from Harvard and had performed this surgery many times without error.
A surgeon who reviewed the case for the state Department of Health, Christian Birkedal of Ormond Beach, said the operation was more difficult than most because the patient had "adhesions" -- scar tissue -- that distorted the abdominal cavity. Birkedal's report said Zaragoza should have opened up the abdomen when he ran into trouble.
Instead, Zaragoza hunted around for the gallbladder; he even took a CT scan. He found what he concluded must be the gallbladder, even though it didn't look like one. He assumed its odd appearance meant it must be covered by a tumor.
That decision made, he severed the blood vessels, removed the organ and sent a sample to pathology. Then came the bad news.
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In the year following the mistake, Zaragoza negotiated a deal with investigators from the Florida Department of Health whereby he would pay a $5,000 fine, but according to the article, that punishment would not include disclosure of the incident to the National Practitioners Databank. The state medical board's ruling body, however, wasn't prepared to let Zaragoza off with such a light punishment.
On a 6-6 tie vote, the board rejected the settlement agreement and counter-offered one that was more serious: a reprimand, $10,000 fine and other standard penalties, such as community service and taking classes. That passed 7 to 6.
Zaragoza has some time to decide whether to accept the counter-offer, which could ruffle his relationships with insurers.
The doctor was due to make that decision this summer. When I find out, I'll post an update.
UPDATE: No answer at Zaragoza's office in Coral Springs.