Hospital fined $50K for third wrong site

The Rhode Island Department of Health has issued a reprimand and a fine of $50,000 to Rhode Island Hospital in Providence for its third wrong-site brain surgery in a year. The health department also issued a second compliance order due to this pattern.

On Nov. 23, 2007, the department was notified by the hospital that a wrong-site surgery had been performed, according to a statement released by the health department. Hospitals are required to report such events to the health department within 24 hours. The surgery follows a compliance order issued to the hospital on Aug. 2, 2007, for a pattern of wrong-site/-side surgery dating back to 2001. "This latest event is the hospital's fourth wrong-site surgery in six years," according to the health department statement. (Editor's note: The compliance orders are available on the health department's web site: www.health.ri.gov/hsr/facilities/hospitals/index.php.)

Director of health David R. Gifford, MD, MPH, said in the statement that "[w]e are extremely concerned about this continuing pattern. 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 latest compliance order was issued as the result of preliminary findings from an unannounced inspection following the most recent report from Rhode Island Hospital. Several deficiencies were cited during the inspection, the health department reports. The compliance order requires these corrective actions:

  • The facility must ensure that an unrestricted licensed physician attends all neurosurgical type procedures from beginning to end.
  • For all neurosurgery procedures, the operating physician must complete a timeout 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 information must be verified by both the physician and a nurse or technician assisting with the procedure.
  • The checklist to be used for this protocol must be approved by the health department.
  • Emergency procedures that break from this protocol must be reported to the health department within 48 hours of the surgery.
  • The hospital must submit a plan for ensuring that all licensed professionals receive training in this protocol and checklist.

As more information becomes available from the ongoing investigation, new requirements may be imposed on the hospital, Gifford said. The health department's Board of Medical Licensure and Discipline and Board of Nursing also will investigate whether any disciplinary action should be taken against the individual health care professionals involved in the Nov. 23 incident. "The repeated nature of these events suggests a systems problem with patient safety that needs to be addressed," the statement said.

The most recent case happened when, according to the health department, the chief resident started brain surgery on the wrong side of an 82-year-old patient's head. In February 2007, a different doctor performed neurosurgery on the wrong side of another patient's head.

In August 2007, a patient died a few weeks after a third doctor performed brain surgery on the wrong side of his head. That surgery prompted the state to order the hospital to take a series of steps to ensure such a mistake would not happen again, including an independent review of its neurosurgery practices and better verification from doctors of surgery plans.

In a written statement, Rhode Island Hospital said it was working with the Department of Health to minimize the risk of medical errors. "We are committed to continuing to evaluate and implement changes to our policies to help ensure these human errors are caught before they reach the patient," the statement read.

The hospital said it was re-evaluating its training and policies, providing more oversight, giving nursing staff the power to ensure procedures are followed.