Rhode Island Hospital Fined Over Wrong-Site SurgeryNov 3, 2009 | Parker Waichman LLP
Last week, we wrote about the fifth reported botched surgery at the same hospital since 2007. Rhode Island Hospital—the largest hospital in that state—allegedly operated on the wrong body part, described as a wrong-site surgery, five times.
Now, says the Associated Press (AP), the hospital has been fined $150,000 and mandated to take what the AP described as “the extraordinary step” of putting in video cameras in its operating rooms, citing Rhode Island health officials. The unprecedented move involves a nonsurgical team clinician observing hospital surgeries for one year, monitoring if surgeons are marking operation sites, and taking time outs to determine if the correct body part has been located for surgery, said the AP.
Rhode Island Hospital has 45 days to install the recording equipment in its operating rooms and every doctor will be taped during surgery at least twice a year, reported the AP. It will be at the hospital’s discretion to advice surgeons if they are being monitored.
Health officials and the State Department of Health were looking into how a surgeon at the hospital mistakenly operated on the wrong area of a patient’s hand. That alleged mistake represented the fifth such wrong-site surgery in two years at the hospital, a teaching hospital for Brown University’s Alpert Medical School. According to state health director, David Gifford, the $150,000 fine represents the second such fine in as many years, said the AP. The prior fine, for $50,000, was imposed following three wrong site neurosurgeries in 2007, added the AP, noting that, according to Gifford, these are the only two fines ever issued by his department.
While this was the third wrong-site surgery in one year, Rhode Island News reported that that surgery was the fourth wrong-site surgery in just six years, all taking place in the neurosurgery area.
The recent surgery, based on a letter previously cited by the AP, revealed that Hospital President Timothy Babineau said the error occurred late last week on a patient scheduled to undergo surgery on two fingers meant for a joint on one of the fingers, but operated on another finger. Babineau said, reported the AP, the surgery was then performed on the correct finger. The patient has since been released.
According to the AP’s recent report providing additional details on the scandal, the surgery was meant for two fingers; however the surgeon performed two operations on the same finger. The site of the planned surgery was to have been indicated, with the team ensuring—prior to making an incision—that they were operating on the correct patient, the correct procedure, and the correct body part, said the AP. The protocols are long established in the medical field and also include marking of the body part scheduled for the operation.
According to Gifford, the surgical team marked the wrist, not each of the two fingers; the surgeon did not mark the site, and the team did not take a “time-out” prior to the second surgery, said the AP. Apparently, when the error was discovered, the team confirmed with the family of the patient if they should conduct the correct surgery on the correct site, said the AP, but—astonishingly—even after the mistakes already made, the team still did not conduct the recommended timeout, a mistake Gifford described as “amazing.”