An orthopedic surgeon at Rhode Island Hospital operated on the wrong finger during outpatient hand surgery on Thursday, the fifth in a string of wrong-site surgeries at the hospital over the past 2½ years.
The mistake occurred despite multiple efforts to eliminate such errors, including statewide adoption of surgical safety procedures and a recent collaboration between Rhode Island Hospital and the Joint Commission, an accrediting agency.
Frustrated in capital letters is probably the way to describe the mood here at the department, said state Health Director David R. Gifford. In 2007, the department reprimanded Rhode Island Hospital and fined it $50,000 for the third wrong-site error that year, each involving a different doctor drilling into the wrong side of a patients head to drain blood.
Asked whether he thought there was something fundamentally awry at Rhode Island Hospital, Gifford said, I am wondering that myself. But he emphasized that he still had not heard all the facts. Health Department investigators were at the hospital all day Friday.
Mary Reich Cooper, senior vice president and chief quality officer at the hospitals parent company, Lifespan, said that Thursdays incident did not reflect a pattern at Rhode Island Hospital, the states largest hospital and Brown Universitys main teaching hospital. Rather, she said, it demonstrates the difficulty and complexity of preventing such errors despite what she described as the hospitals deep commitment to safety.
The team involved in Thursdays surgery followed the protocols correctly verifying the patient, procedure and site but misinterpreted one aspect of the rules, Cooper said. The team regarded the surgery as a single operation on a hand, rather than two separate procedures on two fingers. So the verification protocols were followed only once, and only the hand was marked rather than the individual fingers. In the future, Cooper said, surgical teams will mark each finger and verify the finger before each procedure.
Cooper gave this account of the incident. After the team had verified that they were performing the right procedure on the correct hand of the right patient, the surgeon operated correctly on one finger. Without re-verifying, he then performed the second surgery on a different joint of the same finger. But he was supposed to operate on a different finger. The patients illness affected the entire hand so it was not obvious that the doctor was working on the wrong joint, Cooper said.
The error was noticed before the patient left the operating room. The patients relative, informed of the error, gave permission to perform the surgery on the correct finger. That surgery was done without incident and the patient went home that day.
The team immediately reported the incident to the hospital administration. The surgeon canceled his remaining surgeries for the day and the surgical team spent the day on administrative leave, analyzing what went wrong. Most were back at work Friday.
Cooper described the surgeon as a great surgeon with a great reputation who was deeply focused on performing the procedure correctly. The leadership at Rhode Island Hospital, she said, is committed to safety. Every time one of these kinds of things happen, that commitment is just made stronger, she said.
The previous wrong-site surgery at Rhode Island Hospital occurred in May, when a surgeon operated on the wrong side of a childs mouth during a procedure to correct a cleft palate. The hospital did not have any protocol for verifying surgical sites in places that, like the inside of the mouth, cannot be marked. The surgeon did mark the outside of the childs face, but he marked the wrong side and failed to verify it with the surgical team.
