The Rhode Island Department of Health fined Rhode Island Hospital $50,000 and issued it a compliance order last week after a doctor began to operate on the wrong side of a patient's head. The incident marks the third wrong-site procedure at the hospital this year.
The hospital's chief of neurosurgery, a clinical professor at Alpert Medical School, resigned from his post but will continue practicing medicine at the hospital, the Providence Journal reported Nov. 30.
On Nov. 23, a resident physician began a procedure on the wrong side of an 82-year-old patient's head before realizing the mistake, according to a statement from the hospital, one of the University's seven teaching hospitals. After a stitch to close the wound, the procedure was performed "with good results," the statement said.
The Health Department's order to the hospital noted there is no evidence that the patient's history, physical, preoperative note, consent form or CT scans were reviewed before the operation. "Corrective action and counseling" with all staff involved has taken place, the hospital's statement said.
This was the third wrong-site procedure so far this year at Rhode Island Hospital - all in neurosurgery.
The hospital's chief of neurosurgery, Associate Professor of Clinical Neurosciences John Duncan III, resigned last week, and Associate Professor of Clinical Neurosciences Curtis Doberstein has taken over as interim chief, the Journal reported Nov. 30. The hospital said no decisions have been made on a permanent replacement, and that Duncan will continue to be able to practice at the hospital.
Spokesmen from Rhode Island Hospital were unavailable for comment.
"Any is too many," Andrea Bagnall Degos, a Health Department spokeswoman, said of the incidents. The department's compliance order will require the presence of an attending physician during all neurosurgical procedures, a move the hospital has already taken, the statement said.
David Gifford, director of the Health Department, issued the compliance order Nov. 26 after a surprise inspection following the incident. The order also requires the hospital to submit a report by Dec. 15 with a plan to educate staff on "assuring the right procedure at the right site for the right patient." The hospital will be required to submit quarterly reports on its implementation.
Patients can take measures to ensure their procedures go smoothly, Bagnall Degos said, including asking for the site to be marked and getting as much information about the procedure as possible.
The hospital has hired four independent consultants to review its neurosurgery procedures, it said in a statement. Though the Dec. 15 report to the Health Department will not be available to the public, the hospital said it has already begun to implement its consultants' early recommendations.
"We have begun to institute a cultural change at Rhode Island Hospital," the statement said, "but as fast as we are moving, we know it's not fast enough.
