instrumentation and tools, including the two titanium implant rods crucial for the surgery. The kit was ordered from two suppliers because part of it was out of stock and per HCM policy kits are to be inventoried prior to surgery. The kit was not inventoried prior to the surgery and Nurse Barry notified Dr. Ricketson of the discrepancy after arrival on 01/27/01 before scheduled surgery on 01/29/01. The doctor in question, ignored Nurse Barry and proceeded with the surgery removing Arturo’s vertebrae in preparation for implanting the rods only to find out the rods were not in the kit. Medtronic was notified and advised Dr. Ricketson that the rods could be delivered in 90 minutes. He decided not to wait 90 minutes and implanted a screwdriver shaft into Arturo's spine, creating an improvised unilateral rod. The shaft was not intended or approved for human implantation. Dr. Ricketson never advised Arturo of the screwdriver being implanted inside instead of the rods. The patient was discharged home and cleared for physical therapy and to drive.

Malpractice Case 3 The screwdriver shaft failed a few days later by shattering causing Arturo to undergo another surgery to remove fragments. Nurse Janelle Feld Meyer was present for both surgeries and obtained parts of the screwdriver shaft after it was removed. She then took them to a lawyer since her supervisor failed to advise the patient why his surgery failed. The patient continued to have problems and died two years after his initial surgery.