Errors in New England strike two hospitals
Two recent mistakes at hospitals in Rhode Island and Connecticut remind providers that egregious mistakes can happen to any health care provider if you let your guard down and don’t follow recommended procedures. In the Rhode Island instance, a surgeon operated on the wrong side of a patient’s head, and in Connecticut, two patients died after they were mistakenly given nitrous oxide in surgery instead of oxygen.
At Rhode Island Hospital in Providence, a surgeon operated on the wrong side of a man’s head after a CT scan was placed backward on an X-ray viewing box, according to information the hospital provided to the state Department of Health. The patient was being treated for bleeding on the right side of his brain, but the reversed scan made it look as if the bleeding was on the left. Contrary to the latest recommendations on avoiding wrong-site surgery, the hospital says the correct operative site had not been marked on the body prior to surgery.
The surgeon drilled two holes in the left side of the patient’s skull but could not find the expected bleeding. Realizing that he had operated on the wrong side, the surgeon repeated the procedure on the right side, and the blood was drained. The hospital reports that the patient suffered no adverse effects from the mistake (other than having two unnecessary holes drilled in his head.)
The state department of health cited the hospital for not following its own policies requiring staff to verify the site of surgery in several ways. In addition, the surgeon, two surgical residents, the operating room nurse, the operating room technologist, and the certified registered nurse anesthetist have all been referred to their licensing boards for investigation. A year earlier at the same hospital, another mix-up led a surgeon to operate on the wrong child. A girl who was supposed to have eye surgery instead had her tonsils and adenoids removed.
In two incidents at the Hospital of St. Raphael in New Haven, CT, patients died because they were mistakenly administered nitrous oxide during a procedure instead of oxygen largely due to an equipment mistake. The accidents occurred when an oxygen flowmeter was incorrectly connected to the outlet providing nitrous oxide. Both women were undergoing cardiac catheterization. The first incident occurred on Jan. 11, 2002, but the mistake was not noticed even after the patient died from lack of oxygen, says Charles Riordan, MD, vice president of medical affairs.
The patient’s condition was such that her death during the procedure was not extraordinary, he says. But the same thing happened again on Jan. 15, and that patient’s death was sufficiently surprising to prompt the staff into an immediate investigation. Within minutes, the cardiac catheterization staff immediately reported the suspicious death and the hospital shut down the procedure room and another next door, Riordan says.
A multidisciplinary team representing the medical staff, nursing, biomedical engineering, respiratory therapy, and other departments studied the situation and found that a safety prong on the oxygen flowmeter was missing, allowing it to be connected to the nitrous oxide supply. The hospital checked all the other flowmeters in the hospital and found no problems, Riordan says.
The hospital’s investigation is ongoing, and the state health department sent two investigators to the hospital the day after the second death. The state report is pending. One key question still to be answered is how and why the flowmeter prong was removed, allowing the mistake to happen. The prong or pin is part of a design added to the flowmeter, along with color coding, in recent years specifically to prevent improper gas hookups. In fact, experts in medical errors often cite that change as one of the big success stories in reducing medical errors, saying that such mistakes are virtually impossible now with the improved design of the flowmeters.
Riordan concedes that the two deaths were the result of a series of errors. "Our preliminary assessment indicates that a combination of factors, including a faulty oxygen flowmeter, systemic failures, and human error," he says.
The Food and Drug Administration took possession of the faulty flowmeter and is analyzing it to determine how the prong was removed.
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