Rhode Island Hospital Performs 5th Wrong Site Surgery

Wrong-site surgery is a devastating problem that affects both the patient and surgeon and results from poor preoperative planning, lack of institutional controls, failure of the surgeon to exercise due care, or a simple mistake in communication between the patient and the surgeon. Even though Rhode Island Hospital seemed to be following procedure and has protocol in place to prevent these incidents, 5 wrong site surgeries over the past two years is a glaring problem.

A surgeon at Rhode Island Hospital operated on the wrong finger during outpatient hand surgery on Thursday, a hospital statement acknowledged Friday morning. The patient was scheduled for surgery on two fingers. A joint on one finger underwent a procedure intended for another finger, hospital president Timothy J. Babineau said in a letter to employees. In this case, the wrong finger was operated upon after the correct hand was marked before surgery, but the correct finger was not marked.

Babineau's statement said that the hospital is conducting "a thorough analysis" of what went wrong. It seems as though there is an issue with a set of procedures including a "time out", which is a
pause before surgery when the operating room staff follows a set of procedures to verify they are performing the right surgery on the right part of the right patient. Problems with this process have caused other wrong-site surgery errors at the hospital.

Rhode Island Hospital has participated in a national program called The Rhode Island Universal Protocol Project: Further Reducing the Risk of Wrong Site Surgery. This project was initiated in July 2009 by two Rhode Island hospitals affiliated with the Lifespan system: Rhode Island Hospital and Newport Hospital. The hospitals wanted to collaborate with The Joint Commission on a project to improve the safeguards to prevent patients from wrong site, wrong side and wrong patient surgical procedures.

The wrong site surgery prior to this one was performed on a child who needed a cleft palate repair. The wrong side of the child's mouth was operated upon. The wrong side of the mouth was indicated on the skin by the surgeon and staff did not catch the mistake.

Rhode Island Hospital has a history of wrong site surgeries with three wrong site brain surgeries performed in one year. Those mistakes, coupled with the three surgeries this year, have led to a large fine and potentially further action against the hospital.

Rhode Island Hospital was fined $50,000 after brain surgeons operated on the wrong side of patients' heads in three separate cases in 2007.

Cheryl Phillips
Exclusive to HULIQ.com

sources: Providence Journal, The Joint Commission,