This article was featured in One Great Story, New York’s reading recommendation newsletter. Sign up here to get it nightly.
Bill Bryan woke up one morning in August with left shoulder pain. He and his wife, Beverly, had been spending some time at the condo they’d bought and usually rented out in Okaloosa County, Florida. He’d been moving furniture for much of the prior day and assumed that’s why he was in pain. But as the hours ticked on, the pain spread down his side, and by that evening he couldn’t walk. Beverly drove him to a nearby hospital, Ascension Sacred Heart Emerald Coast. Tests there revealed a mass on Bill’s spleen, which made sense. When a spleen ruptures, it can irritate a nerve that runs from the neck down through the left side of the chest.
Bill spent a couple days in the hospital receiving pain medication and undergoing more tests. With his pain stable, the couple told the hospital that they wanted to go home to their full-time residence in Alabama to receive further care. But Thomas Shaknovsky, an osteopathic physician practicing at ASHEC, disagreed with this plan. If Bill left the hospital, Beverly recalls the doctor warning, “he will bleed to death.”
Shaknovsky said the only path forward was surgery to remove Bill’s spleen, according to a Florida Department of Health report. So late in the day on August 21, Beverly, her daughter, and Bill’s daughter hugged Bill good-bye as he was wheeled into the operating room. “I thought a splenectomy was a fairly simple procedure,” Beverly says. “It seemed like he would be in and out.”
Less than an hour later, Beverly overheard an emergency announcement on the intercom for the operating room Bill was in. No one could answer her questions about what was happening. She decided to wait in the chapel, and eventually Shaknovsky came in, accompanied by “a legion of people,” Beverly recalls. “They said that Bill had not survived.”
Beverly remembers Shaknovsky explaining that Bill’s spleen had “turned out to be very diseased”—that it was four times the normal size and “very heavy.” He also said that a splenic-artery aneurysm had ruptured, causing Bill to bleed to death. Beverly had spent her career in health care, including as an emergency-medicine nurse, and she recalls questions swirling through her head: Why hadn’t Bill’s CT scans and MRIs revealed the advanced stage of the disease in his spleen? Given that his spleen was being removed, why hadn’t the doctor just clamped the artery off to begin with?
In her shock, though, Beverly pushed her questions aside and signed the paperwork. Bill’s body remained in Florida for cremation. Back home, to avoid confused looks from her friends in the medical field, she simply stated that Bill had died of an aneurysm.
But the day after Bill’s celebration-of-life service, Beverly received a call from a medical examiner in Florida. The medical examiner, according to a Florida Department of Health report, said that a pathologist had found something suspicious in the specimen container that Shaknovsky’s team had marked “spleen,” necessitating an autopsy of Bill’s body. According to the medical examiner, the autopsy revealed that Bill’s spleen was still intact inside his body and appeared untouched. The report stated there was no evidence that he had endured a ruptured-splenic-artery aneurysm. But Bill’s inferior vena cava — the largest vein in the body, which connects the liver to the heart — had been dissected, with no indication that anyone had attempted to stop the bleeding with a clamp. His liver was also gone and was in the container marked “spleen,” according to both the Department of Health’s report and a report from the Agency for Health Care Administration, which includes interviews with hospital staff who were in Bill’s operating room.
The case, which is still under investigation, is horrific yet not unheard of. It’s an exceptionally egregious example of what doctors refer to as a “never event,” so named because preventable errors with grave consequences should never happen. In reality, events like these happen more often than most people realize. But unless a patient’s family publicly intends to sue, as Beverly does, they can remain a secret among the hospital employees who were involved. The Joint Commission, the main accrediting body for hospitals in the U.S., only asks hospitals to voluntarily report events that result in death or severe harm to patients, and only a few states report their never events publicly — most notably, Minnesota, which reported 610 adverse health events in 2023, nearly 40 percent of which resulted in severe injuries or death. But reliable national data for the U.S. as a whole do not exist.
I contacted nine physicians to ask about never events for this article, and most did not answer my emails or refused to discuss the topic. Eventually, however, I reached several advocates for health-care safety — including two doctors — who stressed that hospitals will see a reduction in never events only if the stigma surrounding them lifts, allowing them to closely examine the aspects of their protocols that allow these events to occur. Never events continue to happen because health care is complex, but also because the industry is “very poor at learning from our own mistakes,” says Kamal Mahawar, a consultant general and bariatric surgeon at Sunderland Royal Hospital in the U.K.
When never event was coined in 2001, it originally referred only to the most extreme medical errors. But over the past two decades, the phrase has come to encompass, more broadly, any severe adverse medical result that should have been preventable. In the U.S., never events are defined as 29 serious medical errors grouped into seven categories. They include conducting surgery on the wrong site or the wrong patient; killing or seriously injuring someone by giving them the wrong drug; performing artificial insemination with the wrong sperm or egg; the death or serious injury of a mother or newborn during the delivery of a low-risk pregnancy; patient elopement from the hospital; a serious injury or death from the result of falling while in a health care facility; and criminal events such as a patient being sexually or physically assaulted.
Many never events neither result in a patient’s death nor cause lasting physical damage. In England, where national data are available, wrong-site surgery is the most common never event, followed by retention of a foreign object — such as a swab, guide wire, needle, or instrument — in a patient’s body after surgery. In a 2003 survey of 1,050 hand surgeons in the U.S., 21 percent admitted to having operated on the wrong site at least once in their career.
Never events are rarely caused by a single practitioner. “You can imagine, no one goes to work to make a mistake or do harm,” Mahawar says. In fact, just about every protocol in a hospital — from hiring to training to caregiving — is set up to prevent them. But health-care workers, like workers in any job, sometimes accidentally or intentionally break with protocol. And in most cases of never events, systemic hospital dysfunction or disorganization allows those mistakes to add up to serious consequences. Doctors refer to this as “the Swiss-cheese model,” says Matt Austin, an associate professor and a principal faculty member at the Johns Hopkins Armstrong Institute for Patient Safety and Quality. “It’s often a series of circumstances that create the opportunity for an error.”
David Ring is an orthopedic surgeon and the associate dean for comprehensive care at the University of Texas at Austin Dell Medical School. He was involved in a never event more than a decade ago at Massachusetts General Hospital, when he accidentally performed a carpal-tunnel release rather than a trigger-finger release on a patient. Fifteen minutes later, while dictating the operation report in his office, he realized he had performed the wrong procedure. “It was absolutely devastating,” he says.
It was Ring’s sixth and final surgery of the day; an earlier patient had been distressed during her otherwise successful operation, an unusual situation that weighed on Ring. The surgery floor was also behind schedule, so administrators moved Ring’s final patient to a different operating room, which led to what he describes as a “change in personnel.” This meant the nurse who had performed the patient’s preoperative assessment would no longer be in the room with Ring and the rest of the team. Other seemingly small but significant breaks with protocol occurred: There was no tourniquet in the operating room, so the circulating nurse had to leave and get one, distracting her from the patient. The soap and alcohol used to clean the patient’s arm wiped away the surgical marking left by the preoperative nurse. There was no translator available, so Ring — the only Spanish speaker in the room — was left to communicate with the patient, who spoke only Spanish, a language the nurses did not understand. That caused further confusion as to when the operation had formally begun. There was even a nursing change in the middle of the procedure.
When Ring realized his mistake after it was all over, he immediately informed other staff members, then apologized to the patient and asked if he could perform the correct procedure. She agreed. He gathered a new team to do it and the trigger-release went smoothly. The patient was discharged later that day, but Ring and his patient were both irreparably changed. Ring kept in touch with the patient’s family afterward, but ultimately the patient decided not to see Ring again and instead went to her primary-care doctor at a community clinic to have her sutures removed. All charges for the surgery were waived, and a settlement between the hospital’s malpractice insurer and the patient was reached shortly thereafter.
While many people would never want to speak about such an error, Ring did something unusual: He embarked on what he calls “the wrong-procedure world tour.” He shared the story of his never event at conferences packed with thousands of attendees and published an academic case study detailing the errors he made. “I took the approach of talking about it openly,” he says. “I needed that to heal.”
He also thought that speaking about what happened to him might help remove the stigma of these events, making it easier for others to speak up when they were involved in one, and prevent them from occurring in the future. “To err is human,” Ring said. “Never events are not talked about enough.” He suspects that deep shame prevents most other health-care workers from coming forward the way he did and that part of that comes with the outcome having “never” in its name. Labeling something a never event, he says, suggests that the error was made by a bad apple who needs to be found and punished, which makes staying silent seem like a safer choice.
While it might appear, at first glance, as if Bryan simply died at the hands of one truly inept doctor, hospitals have systems in place to protect against any single human error — whether a doctor is exhausted, momentarily distracted, or genuinely incompetent or malicious and shouldn’t be practicing medicine in the first place. “There should be enough checks and balances in health-care delivery that no surgeon ever takes out the wrong organ,” says Leah Binder, chief executive officer and president of the Leapfrog Group, a nonprofit health-care watchdog organization based in Washington, D.C.
A report released in September by Florida’s Department of Health outlines hospitalwide points of failure that led to Bryan’s demise. First, Shaknovsky ordered Bryan’s splenectomy, warning him of his decreasing hemoglobin, though, according to the report, it had decreased only “marginally” over the course of three days. The procedure began unusually late in the day, after 5 p.m., with only a skeletal crew present — meaning the staff would be less equipped to respond to potential complications. A number of Ascension’s operating-room staff also reported that they were worried that Shaknovsky “did not have the skill level to safely perform this procedure.” Shaknovsky had an established pattern of errors in the operating room. Most seriously, in 2023, he removed a portion of a 58-year-old man’s pancreas instead of a mass on his adrenal gland. The patient survived but was permanently harmed, according to the Department of Health report. Shaknovsky was allowed to continue practicing medicine at ASHEC.
After Shaknovsky performed his first major error — cutting Bryan’s inferior vena cava, causing him to severely hemorrhage — he persisted in “dissecting even though the abdomen was full of blood and there was no visibility,” the report states. Shaknovsky also did not take a clamp that a technician offered, which could have stopped the bleeding. Instead, he “fired the stapling device blindly” into Bryan’s abdomen, according to the report. When Shaknovsky removed Bryan’s liver and stated to the other staff that it was a spleen, no one protested, even though they recognized it was a liver. The Agency for Health Care Administration interviewed the operating room staff after Bryan’s death, and when one employee was asked if they were comfortable speaking up, they answered, “I’m a scrub tech and the surgeon won’t listen to a scrub tech unfortunately.”
The Department of Health report states that the person responsible for sending the specimen to the pathologist also realized that the organ wasn’t a spleen, but they presumably viewed their role as largely to follow orders, and so they “did as they were instructed” and labeled it as such. Shaknovsky repeatedly stated to the room that Bryan had died of a splenic-artery aneurysm in an attempt, the staff felt, “to convince them that this is what occurred, even though they witnessed something different,” the Health Department report continued. “We all were like in shock,” a registered nurse told investigators later, according to the Agency for Health Care Administration report. (Says Ring, “The fact that no one in the operating room felt comfortable to speak up suggests that they didn’t have a good safety culture.”)
When Beverly returned to the hospital the day after Bill died, she asked members of the OR team what they remembered from Bill’s surgery, and they continued to keep mum. “No one said anything about his liver being removed,” says Beverly. Adds Joe Zarzaur, the attorney Beverly hired, “All these people knew that something was wrong — that something horrible had just happened. But no one said a thing.”
According to Mahawar, most never events could be prevented if health-care facilities seriously addressed their underlying drivers and developed systematic barriers. He says that the first step is to critically examine all the factors that went wrong, including through consultation with family members and the patient, if they survived. Once all the data is in, hospitals should devise fixes to prevent the mistake from ever being repeated, and find ways to share those fixes with other facilities. Binder and her colleagues also recommend that hospitals waive all costs related to the event and, as obvious as this may seem, directly apologize to the patient and their family for the mistake they made.
Shaknovsky’s medical license has now been suspended by the Florida State Surgeon General and the Alabama Medical Licensure Commission. Ascension Florida, which includes the hospital where Bill died, declined an interview request for this story. A hospital spokesperson said, “Dr. Shaknovsky has never been a Sacred Heart Emerald Coast employee and no longer practices medicine at Sacred Heart Emerald Coast or any of our other facilities. Our organization does not discuss specific patient cases and will not provide further comments.” (Zarzaur explained it is common for hospitals to hire specialists on an “independent contractor basis” to protect themselves from liability.) Shaknovsky’s attorney did not respond to a request for comment.
Beverly has yet to receive any apology or admission of wrongdoing. “Bill was the last person in the world this should have happened to,” she says. “He has children and grandchildren and a little dog that love him and miss him terribly.”
