An audit by the Health Superintendence revealed that Hospital Ingavi, part of the Social Security Institute (IPS), ignored safety protocols and attempted to destroy evidence after removing the wrong breast from a 62-year-old cancer patient. The report points to documentary, operational, organizational, and communication failures within the medical team, as well as tampering with evidence — including manipulation of the surgical record and editing of the electronic system to justify the error.
Patient Nanzi Franco had a confirmed diagnosis of invasive carcinoma in the right breast, information that was recorded in her medical records, complementary exams, and the informed consent form. Despite this, the medical team performed the mastectomy and sentinel lymph node biopsy on the left breast. According to the report, the patient herself informed the anesthesiologist, before surgery, which breast was affected, but the professionals ignored the information and omitted the safety pause known as "time out." The breast marking was done inside the operating room, when the patient was already under anesthesia — the protocol requires this step to occur beforehand, with the patient's participation.
Attorney Carmen Pereira, legal representative of Nanzi Franco, stated that the report will reinforce the arguments of the investigation opened by the prosecutor's office. "Who takes responsibility for these acts? There was a breakdown in all processes," she declared. The patient's daughter, Natalia Benítez, criticized the doctors for not even having consulted her mother's medical records. "The one who was following up was the breast specialist, and that same breast specialist operated on her. The responsibility lies with the entire medical team that was in the room," she stated.
Health Superintendent Roberto Melgarejo detailed that the audit detected significant weaknesses in the hospital's computer system and that a temporary suspension of surgeries at Ingavi is being analyzed if new irregularities are confirmed. "Initially we see that there is a significant weakness in the computer system," he highlighted. The Superintendence recommended that all personnel involved in surgical procedures know and strictly comply with safety protocols and reported that the report has already been forwarded to the prosecutor's office.
After the report was released, IPS announced the complete renewal of the Mastology Department team and the appointment of a new head for the area. Derléis León, the institute's Health Manager, classified the case as an "unfortunate event" and announced the opening of summary administrative proceedings, with an estimated timeframe of 60 business days. Walter Laguardia, Director of Internal Audit, stated that there are "many coincidences" between the Superintendence's findings and the internal investigation conducted in parallel by IPS. Legal Director Pablo Morínigo confirmed that the case could result in civil, administrative, and criminal consequences.
Irene Giménez, coordinator of the Health Management Office, admitted that critical weaknesses were detected in pre-surgical control, during the procedure, and in the postoperative phase. As mitigation measures, IPS plans to make the digitization of medical records mandatory and strengthen the traceability of records. "There were errors in the chain. These are errors that happened and that will be corrected. Computerized control is necessary; the records must be digitized; it is a weakness we found," she acknowledged.
The audit also identified alteration of material, break in traceability at the pharmacy, deficiency in supervision and hierarchical control, manipulation of medical verification parameters, and vulnerability of the computer system. The report was forwarded to the Ministry of Health for investigation of possible offenses and recommended summary administrative proceedings for the entire team involved in the surgery.