Massachusetts residents who are considering knee replacement surgery may be interested to know that an error occurred during this procedure at San Coronado Hospital in California on April 2012 due to a vendor rep taking the wrong box off a shelf. The patient then had to have a second knee surgery to correct the placement of the wrong tibial joint. The facts reported stated that a representative for the manufacturer of replacement knee joints was the person who retrieved the box with the wrong joint in it and gave it to the surgeon during the surgery. Unfortunately, incidents like this are not uncommon.

This error was reported in a recently prepared database that has been created by the Association of Health Care Journalists. This database contains 8,000 violations of federal safety regulations that have occurred since January 2011. This particular case is an extreme example of surgical errors. This action violated practices of the Association of perioperative Register Nurses, and it should be a cause of concern for surgeons and medical consumers alike. There was no lawsuit against the hospital involved, and they are now investigating their protocols for vendor representatives involved in procedures.

The Association of Health Care Journalists has also created a website containing this information that can be searched by anyone who is interested. The website,, is a compilation of material just released from the federal Centers for Medicare & Medicaid Services.

Most surgical errors are preventable. This case might not have occurred if the box and the tibial joint were double-checked before they were inserted into the patient. Medical consumers in Massachusetts who have suffered from surgical errors may benefit from speaking with a medical malpractice attorney.

SOURCE: CoronadoPatch, “Wrong Box Pulled from Shelf Sparked U.S. Probe of Hospital Implant Flub,” Ken Stone, March 18, 2013