R.I. Hospital fined $50,000 for wrong-site surgery

PROVIDENCE – The R.I. Department of Health said today that it has issued a reprimand to Rhode Island Hospital and fined the facility $50,000 for its third wrong-site surgery this year.

The surgery, which occurred Friday, involved an 82-year-old patient in the neurosurgical intensive-care unit, the hospital said in a statement. A resident was performing a bedside procedure, and “prior to entering the skull, it was determined that the procedure was being performed on the wrong side and it was immediately stopped.”

The patient received one stitch to close the wound, the hospital said, and the procedure was then performed on the correct side, with “good results.”

But the mishap comes at a particularly sensitive time for the hospital, which was already under scrutiny from the state because of a surgery July 30 involving an 86-year-old man who underwent a wrong-side craniotomy. A review of that incident had found, as officials put it in a subsequent compliance order to Rhode Island Hospital, that “hospital surgical safeguards are deficient and that some systems were not followed.”

- Advertisement -

The error on Friday was the hospital’s fourth wrong-site surgery in six years, according to the Department of Health. The hospital said “corrective action and counseling have occurred, with all the individuals involved,” but the state still issued a new compliance order today.

“We are extremely concerned about this continuing pattern,” said Dr. David R. Gifford, the state health director, in a news release. “We have not seen an adequate response in the hospital’s system and protocols since the last compliance order was issued. While the hospital has made improvements in the operating room, they have not extended these changes to the rest of the hospital.”

The Department of Health said it conducted an unannounced inspection at the hospital yesterday after the Nov. 23 incident, and “several deficiencies were cited during the inspection,“ resulting in the fine.

The compliance order requires the hospital to ensure that an unrestricted licensed physician attend all neurosurgical-type procedures from beginning to end, officials said.
For all neurosurgery procedures, it requires the to operating physician complete a time-out checklist that at a minimum confirms the correct patient, procedure and surgery site by reviewing imaging, consent forms and medical records before proceeding with the procedure. The physician and a nurse or technician assisting with the surgery must verify the information as well, officials said.

Emergency procedures that break from this protocol must be reported to the state within 48 hours, officials said, and the hospital must submit a plan for ensuring that all licensed professionals receive training in the protocol and checklist.

The hospital has been working with an independent quality consultant and three expert physicians to review and monitor its neurosurgery practices since last August, according to the Department of Health, and reports from those experts are due to be delivered to state officials by Dec. 15.

The R.I. Board of Medical Licensure and Discipline and Board of Nursing will also investigate whether any disciplinary action should be taken against the individual people involved in Friday’s incident, officials said, though a news release added that “the repeated nature of these events suggests a system and culture problem with patient safety that needs to be addressed.”

In its statement, the hospital said that “we have talented, dedicated professionals working hard to provide the best care to our patients, but we clearly need to do more.”

“Our policies and procedures cannot be effective unless every person understands them and follows them to the letter,” the statement continues. “We have begun to institute a cultural change at Rhode Island Hospital, continuing to promote patient safety and quality of care as our highest priorities, but as fast as we are moving, we know it’s not fast enough. Changes that are underway include reevaluating training and policies, continue to look at different safety systems, provide more senior level oversight and further empowering nursing staff to ensure our policies and procedures are followed.”

The Nov. 26 and Aug. 2 compliance orders issued to Rhode Island Hospital by the R.I. Department of Health are available from the department’s Division of Health Services Regulation at www.health. ri.gov/hsr/facilities/hospitals.

No posts to display

1 COMMENT

  1. Travelling Trouble

    From the Immediate Compliance Order:
    ?The hospital Risk Manager stated the nurse was a travel nurse and not familiar with the procedure.?
    http://www.health.ri.gov/media/20071126RIHosp.pdf – p 3.

    Hospital procedeures are necessarily becoming more complex. In addition, they tend to be unique to a given environment. Financial pressures and recruitment problems are making the use of “Travellers” more common. Despite their general competency, there can be a prolem with failing to follow hospital procedure, such as in this case, where procedure apparently called for the nurse to independently check and sign off on the correctness of the site.
    Unfortunately, the compliance order does not address this problem.

    William T Blessum, MD JD – wblessum.com