RI fines hospital for surgical errors

Piece of drill bit left in skull

The Rhode Island Department of Health is fining Rhode Island Hospital (RIH) in Providence $300,000 for what the state says is a pattern of significant surgical errors.

The health department received notification from Rhode Island Hospital that during a neurosurgery procedure at RIH on Aug. 4, 2010, a piece of a broken drill bit was left in the patient's skull after the surgery was completed, according to a state report.

The department conducted a joint investigation with the Center for Medicare and Medicaid Services (CMS) and discovered that the hospital "is not actively ensuring that the operating room staff is following existing hospital policy," the report says. "RIH's surgical count policy states that if a surgical tool or device is unaccounted for at the end of surgery, an X-ray of the patient should be done before the patient leaves the operating room to assure that the tool or device is not inside the patient. In this incident, no X-ray was taken, and the surgical count was documented as correct." (To view the health department's statement of deficiencies of the incident, visit http://www.health.ri.gov/discipline/hospitals/RhodeIslandFindings201010.pdf.)

The investigators also found that numerous staff reports of incorrect surgical counts have gone unanswered by the hospital. Similarly, reports from nursing staff that an anesthesiologist did not wear a surgical mask in the operating room were not addressed by medical leadership, according to the report.

The fine is the third and largest imposed against Rhode Island Hospital for surgical errors. In addition to the $300,000 fine from the state, CMS has asked the health department to conduct a full survey of all areas of the hospital and to ensure that the hospital is in compliance with all of the Conditions for Participation for Medicare. (To view the letter to the hospital from CMS and the CMS statement of deficiencies, visit http://www.health.ri.gov/discipline/hospitals/RhodeIslandFederalFindings201010.pdf.) Two physicians and one nurse also are being referred to their licensing boards for review, according to Rhode Island Director of Health David R. Gifford, MD, MPH, who announced the action.

"There is a troubling pattern of disregard for established policies that are designed to protect patient safety and prevent medical errors in Rhode Island Hospital's operating rooms," Gifford said. "When reports from staff about problems in the operating rooms are not adequately addressed, employees are less likely to speak up and report potential problems or concerns."

In addition to the instance with the surgical drill bit, a surgical instrument was discovered on Oct. 15 in the abdomen of a patient who had undergone surgery at Rhode Island Hospital three months earlier, the hospital announced in a news briefing recently. The item was discovered when the patient underwent an imaging test as follow-up for the surgical procedure, and the clinicians were surprised to see a tool that appeared to be forceps, the hospital reported.

The portion of the drill bit was discovered when the patient underwent an MRI. The testing revealed the presence of metal, which the health department says could have been dangerous for the patient if the MRI's magnet had moved it within the patient's head.

Health inspectors also reported that hospital officials failed to respond to "numerous reports" of inaccurate counts of surgical instruments, and did not act on reports of an anesthesiologist who repeatedly walked into the operating room with his mask down.

Mary Reich Cooper, senior vice president and chief quality officer of the hospital's parent company Lifespan, issued a statement indicating that every problem reported is addressed, but that some are not always documented. The health department report described an interview with a risk manager, who confirmed that no investigation was done on a report about sloppy accounting of surgical tools. It also quoted the chief of anesthesia saying that "this was the first time he had heard of the situation" involving the anesthesiologist who wouldn't wear his mask.

The incidents are the latest in a string of surgery-related problems for the hospital. In October 2009, a surgeon at Rhode Island Hospital operated on the wrong finger joint, the fifth wrong-site surgery at the hospital in about three years. The health department fined the hospital $150,000 and ordered it to hire a consultant to observe surgery for three years, shut down surgery for one day, conduct mandatory training on surgical procedures, and install audio- and video-monitoring equipment in the operating rooms for periodic observation.