In Australia, they nicknamed him Dr. Death. In Oregon, Jayant M. Patel was able to freely practice medicine for nearly a decade before state officials sanctioned him.
The reason, many health experts say, is that few hospitals or doctors' groups have solid systems to track every surgery and highlight patterns of problems.
Although doctors now have sophisticated tools to measure cells and genes, the study of what happens in U.S. operating rooms remains surprisingly unscientific.
"It's pretty common understanding in the medical community that what gets measured gets done," said Lisa McGiffert, who leads an effort by the not-for-profit Consumers Union to make hospitals disclose infection rates. "And I think the American public does not know that doctors and hospitals are not looking."
If surgeons and hospitals simply paid more attention to what happens to the people they operate on, patient advocates say, thousands of deaths could be avoided.
Progress has been slowed, they say, because of the cost of building and running tracking systems. There is also the fear among some surgeons of being stigmatized if complication rates become public.
Six states -- not including Oregon -- require hospitals or surgeons to publicly report their error rates on complicated procedures.
Patel was sanctioned by state regulators after his employer, Kaiser Permanente, restricted his practice following a review of 79 of his surgeries.
Kaiser has not said what prompted it to flag those cases.
Today, however, the organization is often cited as one of the few health systems to consistently track patient outcomes using computer programs, as well as data analysts who regularly combine and scan information from patient charts, lab tests, hospital visits and pharmacy records.
Patel is under investigation for surgical problems and patient deaths in Australia, where he landed after leaving Kaiser in 2001.
"As the recent case shows, the community needs to know that dangerous doctors do not operate on patients," said Steve Gordon, M.D., medical director for quality at Providence St. Vincent Medical Center, Portland, Ore.