Wrong-site surgery prompts hospital review
After an instance of wrong-site surgery that still defies explanation, officials at Rhode Island Hospital in Providence agreed to conduct an extensive examination of safety procedures in the surgery department.
John B. Murphy, MD, the hospital's vice president for medical affairs and chief medical officer, announced that the review was required under the terms of a consent agreement with the Rhode Island Health Department. In late May, surgery was suspended for at least two or three hours in each specialty to allow surgeons, anesthesiologists, nurse anesthetists, and nurses to review policies and consider how they apply to each type of surgery. The findings of the review, and any modifications to policy or procedures, were not made public.
The agreement with the health department required the hospital to focus on situations in which current policies may be insufficient. Examples included procedures for marking the correct site when surgery is performed on the mouth, vagina, or eye, or ensuring that the surgeon operates on the correct side of an internal organ.
In addition to staff meetings to review procedures, the agreement requires that the hospital take these steps:
contract with a patient-safety consultant to establish a system for reporting near-misses.
develop methods to regularly confirm that all surgical staff members understand the current policies and procedures.
clarify and standardize its timeout procedure.
Rhode Island Hospital was the subject of an investigation by the health department after a May 11, 2009, incident in which a surgeon began operating on the wrong side of a child's face. The health department's investigation found that the procedure to repair a cleft palate involved removing a small piece of bone from the patient's hip and grafting it in the roof of the mouth. The left side of the mouth previously had been repaired, so the surgery was to address the right side.
Investigators determined that the consent form signed by the parents correctly indicated the surgical site. The surgical team also properly performed a timeout in which all members agreed that the right side of the mouth was the correct surgical site. Even so, the surgeon cut into the left side of the mouth, the health department found.
A surgical resident who was involved in harvesting the bone from the hip noticed the error and called it to the surgeon's attention. At that point, the surgeon stopped and proceeded with the surgery on the right side. The hospital and the health department report that the rest of the surgery was successful and the patient fared well.
David R. Gifford, director of the health department, says the investigation could not determine how the error was made because all the proper procedures were followed. He notes that the willingness of the resident to challenge the surgeon is a positive indicator of the hospital's patient safety culture.
Murphy told The Providence Journal that the error may have occurred, or was not stopped before the surgeon began cutting, because the surgery was intraoral and that limited the ability of everyone else in the room to see where the doctor was working. He also said the patient had some unique characteristics that may have complicated the situation further. Murphy says the hospital revamped its surgical policies and procedures in the past to try to accommodate all possible scenarios, but "we haven't anticipated the millions or billions of situations that may come up."
The consent agreement does not end the health department's investigation. The hospital placed the surgeon on administrative leave and referred him to the medical licensing board for possible disciplinary action. The hospital and the health department determined that the nurses and the rest of the surgical team were not at fault.
After an instance of wrong-site surgery that still defies explanation, officials at Rhode Island Hospital in Providence agreed to conduct an extensive examination of safety procedures in the surgery department.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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