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Rhode Island Hospital Reprimanded for Wrong Site Surgeries

Posted by Jane Akre
Tuesday, November 27, 2007 4:36 PM EST
Category: Major Medical, Protecting Your Family
Tags: Medical Malpractice, Medical Devices, Wrongful Death, Head and Brain Injuries

For more on wrong site surgery, see InjuryBoard's wrong site surgery information page.

Some Tips for Preventing Wrong Site Surgery 

Imagine you are a patient in a hospital about to undergo surgery on your brain.

The anesthesiologist puts you out, you wake up to find out the surgeon began operated on the wrong side of your head.

That is what happened Friday at the Rhode Island Hospital (RIH) to an unidentified 82-year old patient. 

The hospital reports a resident in training began drilling the right side of the patient’s head even though the bleeding was on the left side.  After realizing the error, the hospital reports it took one stitch to close the initial surgery and then the team proceeded correctly on the left side.

The patient is reported to be okay.  

A different doctor at the same hospital performed brain surgery on the wrong side of another patient's head in February.  Then in August, a patient died after a third doctor operated on the wrong side of his head.

Friday's is the fourth “wrong-site surgery,” as it’s called, at this hospital in six years.

RIH, The teaching hospital for Brown University and owned by the not-for-profit corporation Lifespan has now been fined $50,000 and reprimanded.

Last August, after a wrong-site surgery, the Rhode Island Department of Health ordered RIH to have a consultant review the hospital’s neurosurgical procedures.  That had been ongoing up until two weeks ago. 

The hospital says it will now include another physician in the operating room. 

"Effective immediately, all intra-cranial neurosurgery procedures will have an attending physician present for the entire procedure and the timeout process to verify site and side for significant procedures in the operating room or at the bed side will include one physician and a nurse or physician assistant in addition to the resident,” according to a statement.

Jay Wolfson, of the department of Public Health at the University of South Florida, tells IB News that because different surgeons were involved in these missteps, the focus should be on the entire neurosurgery department. 

“This is an elite sub-specialty group and the fact that there were 2 or 3 in neurosurgery alone suggests who is not minding the shop?  There is no excuse for multiple episodes within the same discipline,” he says. 

In Florida after national headlines about a surgical procedure on the wrong leg, the state in 2004 passed a law known as the “pause rule.”

Under the law, the operating physician and the surgical team must pause before surgery. Out loud they name the patient, the procedure and the site and side being operated on.

Rhode Island has no state law regarding the pause rule, but Andrea Bagnall Degos, spokesperson for the Rhode Island Department of Health, tells IB News that it is a standard of practice for accredited hospitals. 

The Rhode Island Hospital is accredited under the national standard developed by the Joint Commission on Accreditation of Healthcare Organization (JCAHO)  that developed universal protocols in 2004. The standard requires the surgical team to verify they have the correct patient and body part during a time-out before operating.

But after the headlines die down, humans will become complacent again warns Wolfson.

“Complacency is the greatest challenge in patient safety.”  He likens repetitive surgery to plumbing and tells his students to “avoid becoming a technician.”  He reminds students they are operating on a person and not performing a task.

As for patients worried about their future under the knife, he suggests the patient take the lead.  “Paste things on yourself, insist on talking with the surgeon and anesthesiologist ahead of time,” he suggests. 

The Joint Commission suggests you be involved in marking the site of surgery with an “x”,  the word “ yes” and the surgeon’s initials. 

Wrong-site surgery is commonplace and the problem is getting worse.  

A study in the Archives of Surgery found that over a 20 year period, of 2.8 million operations, wrong-site occurred in one of every 112,994 surgeries excluding the spine.   

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