ORLANDO, Fla. – A top cardio pediatric thoracic surgeon at Arnold Palmer Children's Hospital told the State Medical Board that all seven hospitals in the Orlando Health Care System have implemented sweeping changes following a mistake in the operating room that led to the wrong valve being implanted in the aortic position of an 11-year-old boy.
[WEB EXTRA: Watch doctor, parent testimony ]
Dr. Kamal Pourmoghadam testified before the Florida Board of Medicine on April 10 to defend allegations of malpractice and wrongful implantation of a mechanical mitral valve placed in the aortic position of 11-year-old Justin Solnay in a surgery that took place March 20, 2013.
According to hospital records, the surgical team didn't recognize the mistake for three days.
Pourmoghadam testified he had completed 50 mechanical transplants prior to the incident and roughly "five or so" after the Solnay surgery.
When asked why the valve issue wasn't picked up in any of the tests that were conducted, the veteran surgeon replied, "I racked my brain, it's not just me. All of us have racked our brains trying to figure out why we didn't see that immediately. I wish I had a good answer for you; I do not."
Pourmoghadam's attorney, Michael D'lugo, said the entire surgical team was upset, unable to explain what went wrong.
"They had systems in place," D'lugo said. "Multiple, multiple systems in place, and they honestly felt as of March 20, 2013, the systems were adequate to catch something like this."
Since that incident, six new safety levels have been introduced, including a white board, to document what valves are to be used in a scheduled surgical procedure.
Solnay's parents, Jim and Patricia, testified before the board as well, asking that Pourmoghadam's license be revoked.
His father, Jim, fought back tears, sobbing, "This so easily could have been avoided."
The family has filed a civil lawsuit arguing their son died five weeks after a St. Jude mechanical mitral valve was "wrongfully and willfully" implanted in the aortic position.
Pourmoghadam was fined $40,000. The civil lawsuit remains unresolved.