The Rhode Island Department of Health reprimanded Rhode Island Hospital yesterday, and fined it $50,000, for its third wrong-site surgery this year, the most recent involving an 82-year-old patient in the neurosurgical intensive care unit.
The incident at the Providence hospital occurred Friday, when a resident, a doctor in training, began drilling into the right side of the patient's head during a bedside procedure. A CT scan had shown bleeding on the left side of the patient's brain. The resident realized the mistake, closed the initial incision, and performed the procedure on the left side.
The hospital reported the error to the health department, which conducted a surprise inspection Sunday.
State health officials had ordered the hospital on Aug. 2, 2007, to improve its procedures, because of a pattern of wrong-site surgery dating back to 2001. This latest incident is the hospital's fourth wrong-site surgery in six years, all involving brain operations.
"We are extremely concerned about this continuing pattern," said Dr. David R. Gifford, director of the agency, in a statement yesterday. "We have not seen an adequate response in the hospital's system and protocols since the last 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."
In July, a surgeon also operated on the wrong side of the brain of a patient who had internal bleeding. Following that incident, the health department ordered the hospital to hire a consultant to review policies and procedures related to neurosurgical services. Health officials also required the hospital to have a second physician review the proper site for all surgical cases prior to surgery.
The hospital said in a statement yesterday that it had put the policy in place for procedures done in the operating room.
As a result of the latest incident, all intra-cranial neurosurgery procedures will have an attending physician present for the entire procedure, hospital officials said.
A "time out" process to verify the site for significant procedures in the operating room or at the bedside will include a physician, a nurse or physician assistant, as well as the resident.
