Wrong-site surgery case leads to probe

As Rhode Island health officials investigate why a neurosurgeon operated on the wrong side of a patient's skull at a Providence hospital Monday, the national group that accredits hospitals said it is reviewing the adequacy of its guidelines intended to prevent such mistakes.

Wrong-site surgery is "a persistent problem in American healthcare," despite years of efforts to combat it, said Dr. Peter Angood, vice president and patient safety officer at the Joint Commission. "No patient wants to have the wrong procedure, and we need to do whatever we can to prevent that."

The error at Rhode Island Hospital was the second time this year a neurosurgeon there performed a procedure on the wrong side of the head, and the third such mix-up since 2001.

Monday's surgery involved an 86-year-old man who required emergency surgery for bleeding between his brain and skull, according to the hospital. The hospital said it has suspended the surgeon who performed the operation, J. Frederick Harrington, pending the outcome of an investigation. In a consent order with the Rhode Island Department of Health, Harrington also agreed not to perform surgeries in any hospital until the department's investigation is complete.

On Thursday the health department ordered the hospital to bring in an outside consultant to monitor its neurosurgery practices and to have a second doctor verify each neurosurgery plan.

This is the first time that the health department has issued a compliance order to a hospital before completing an investigation, the agency's director, Dr. David Gifford, said yesterday.

He said the department took the unprecedented action because the two previous wrong-site surgery incidents raised fears about a systemic problem at the facility.

"Our concern is that while they put policies and procedures in place which look good on paper, they are apparently not being followed and not being monitored," he said.

While the health department has not determined the cause of the accident, Gifford said preliminary interviews suggest that the hospital incorrectly applied at least part of the current Joint Commission safeguards. They require that hospital staff verify that they have the right patient and body part, mark the body part to be operated on, and take a "time out" in the operating room to double-check the surgical site before starting the procedure.

Hospital staff may have written the wrong side of the head on a patient consent form, Gifford said.

Nationwide, hospitals have reported 552 cases of wrong-site surgery to the commission since 1995. The steps to prevent it are simple, Angood said, but depend on effective communication among different teams of health care providers. That communication can break down in an emergency, he said.

The commission developed its standards, known as the universal protocol, in 2004. But state agencies and professional societies continued to report problems with wrong-site surgery, leading the commission to convene a second summit on the issue this February, Angood said. Recommendations from that meeting have yet to be released, and any changes would have to be approved by the commission's board.

The Rhode Island Hospital patient came to the emergency room after a fall three days earlier left him feeling lethargic, according to the hospital's statement. Staff performed a CT scan, which revealed bleeding on the left side of his head, and the patient was rushed into surgery.

Harrington "had reviewed the CT scan previously, but did not accurately remember the side of the bleed," the hospital said in a mandatory report it filed with the health department. After first operating on the right side of the head, the surgeon realized his error and completed the operation on the left.

A hospital spokeswoman said the patient remained hospitalized in stable condition yesterday afternoon.

Harrington's lawyer, Robert Goldberg, said the surgeon is cooperating fully with the health department investigation and said he could not comment further because of that inquiry.

The case earlier this year, in January, also involved bleeding on the brain. A neurosurgical resident placed a drain in the wrong side of a 91-year-old patient's head. The resident and a nurse performed the procedure at the patient's bedside and failed to fill out a required form verifying that the drain was in the right place. The resident later said he knew about the policy, but had never seen the form or seen anyone use it. The hospital promised the health department to better educate staff about the policy.

"We deeply regret the incident," the hospital wrote in its statement Thursday.

"We can and must do better to ensure the safety of our patients."