PROVIDENCE — Rhode Island Hospital has agreed to invest at least $1 million into patient identification and verification systems after a R.I. Department of Health review of four incidents where the hospital misidentified patients, resulting in three tests on the wrong people and a spinal surgery performed on the wrong vertebra between Feb. 21 and March 16.
According to the DOH, the investment will be performed in lieu of regulatory action for the following incidents:
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- Feb. 21: Computed tomography angiography of brain and neck intended for another patient.
- Feb. 26: Angiogram performed on patient intended for another patient.
- March 12: Patient underwent surgical vetebroplasty on C-6 instead of C-7.
- March 16: Mammogram of right breast performed on wrong patient.
A vertebroplasty, according to the Mayo Clinic, is an outpatient procedure for stabilizing compression fractures in the spine. Bone cement is injected into back bones (vertebrae) that have cracked or broken, often because of osteoporosis.
“Regrettably, in February and March, four events occurred at Rhode Island Hospital that were related to aspects of patient identification and diagnostic imaging procedures,” said Margaret M. Van Bree, Rhode Island Hospital President in a memo to hospital staff about the mistakes.
“Patients and families were notified and none of the patients had any complications. Because of our culture of transparency, staff reported the incidents through SafetyNet and the hospital reported the incidents to the Rhode Island Department of Health,” Van Bree said.
The investment will be made in patient identification and verification, verification of procedure site/side, and provider’s orders for diagnostic services, the Department of Health reported in a statement Friday afternoon.
The investment will be applied first to costs the hospital incurs directly related to the errors, including any requirements made by the Joint Commission. “RIH may include as remediation investment expenditures a maximum of $330,000 in salary costs for training and retraining staff in its systems related to patient identification procedures.
The hospital must also report the events to The Joint Commission Office of Quality and Patient Safety within 10 business days of the agreement and request written recommendations from the organization. It must act on those recommendations within 30 days of receiving them. Additionally, the hospital must provide written monthly reports about its progress on implementing the recommendations.
Lifespan Vice President Jane Bruno said that Rhode Island Hospital invests tens of millions each year to promote patient safety.
“Truth be told, there will always be more work to be done in this area. It’s an ongoing effort and it is vitally important to our patients and the community that we get it right, for every patient, every time. To remain among the safest hospitals in the country, we are committed to more robust training and education of all staff to further advance our culture of safety,” Van Bree said.
Rob Borkowski is a PBN staff writer. Email him at Borkowski@PBN.com.
