Hospital Wrong Site Surgery Problems Results in Fine for Safety Violations

Rhode Island Hospital has to pay $150,000 in state fines and is required to install new monitoring equipment in operating rooms following a violation of safety policies that resulted in surgeons operating on the wrong finger of a patient last month. The surgical mistake was the at least the fifth wrong-site surgery at the hospital since 2007.

Following an investigation by the Rhode Island Health Department, it was determined that the hospital failed to adhere to appropriate standards of medical care, and did not follow a state error-prevention program that went into effect this summer, both of which are designed to prevent doctors from performing surgery on the wrong body part.

State regulators said that the hospital should have properly marked the finger that was to be operated on, and should have had a pause before the surgery to verify that the staff was clear on the procedure and the surgical site. The state’s health director, David R. Gifford, said that the hospital had shown a “pattern of surgical errors” which was unacceptable and needed to be corrected to protect patients.

The $150,000 fine is only the second time that the Rhode Island Health Department has fined a hospital in the state, according to the Providence Journal. The other was a $50,000 fine in 2007, which was leveled against the same hospital for problems with wrong-site surgeries.

In addition to the fine, the hospital must install video and audio recording equipment in every operating room, and every surgery performed at the hospital for a year will be done under observation by a licensed clinical professional. The hospital must also perform a day of staff training on wrong site surgery prevention, and adopt statewide surgical safety protocols.

The hospital performed three operations on wrong parts of patients’ brains in 2007, and earlier this year the hospital operated on the wrong side of the mouth of a child with a cleft palate after a surgeon marked the wrong side before surgery.

The hospital had been working with a consulting group to address the problem, and submitted a list of recommendations for wrong site surgery prevention, but hospital officials say that the state rejected those recommendations in favor of its own.

Wrong site surgery is generally considered a “never event,” or a mistake that is inexcusable and should never occur. The American Academy of Orthopaedic Surgeons says wrong site surgery is caused by “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.” The academy notes that 84% of wrong site surgery lawsuits result in payments to plaintiffs, as opposed to 30% of other orthopedic surgery claims.