RI hospital commits fifth wrong-site surgery since January 2007
Staff members at Rhode Island Hospital in Providence, have committed the facility’s fifth wrong-site surgery since January 2007, resulting in a $150,000 fine levied by the state’s Department of Health (DOH), reports The Providence Journal. This is only the second time that the hospital has been fined, the first being after the hospital’s third incorrect neurosurgery occurred in 2007. The latest wrong-site surgery involved a procedure done on a patient’s incorrect finger. In addition, the DOH is requiring that the hospital
- install video and audio monitors in each operating room
- allow a licensed clinical professional who isn’t part of the surgical team to observe every surgery for a year
- adopt the statewide procedure for using safety checklists and marking the surgical site
- summarize each wrong-site surgery since 2005 to send to accrediting and government agencies
- conduct mandatory training sessions for all staff members who work in the operating room to review procedures
Readers, I’m wondering what you, as people who work in hospitals each day, make of this? This hospital, which should have been by all accounts been following the Universal Protocol as well as the state’s guidelines for preventing wrong-site surgery, did not. However, many readers of this blog may know and understand the culture necessary to ensure that the correct steps are taken to prevent a wrong-site surgery. Do you think the requirements made by the Health Department will prove to help this facility sort out its patient safety issues? Do you have any general thought about this instance?
In a related note, the president and CEO of Rhode Island Hospital, Timothy Babineau, MD, has offered to answer questions on the hospital’s Web site through November 9 (not specifically related to this event, but you could get any questions on this topic to him if you so desire).
Please see the Providence Journal article, it does a good job of explaining the story.
About the Author: Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books, webcasts, and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals (www.accreditationprofessional.com) and manages Patient Safety Monitor (www.patientsafetymonitor.com), of which this blog is a part.
Contact Heather by e-mailing hcomak@hcpro.com
Sandra Stanley | Nov 4, 2009 | Reply
The DOH is making a good effort to guide RI hospital toward a culture of safety and preventing never events. Hospital leadership should take a closer look at the Universal Protocol and write policy and procedure for surgical interventions specifically based on the UP.01.01.01, if policy is written, consider maybe revising it to include surgical checklists a “time out” or procedural pause where every individual in that operating room (including the surgeon)stops and properly identifies the patient, informed consent, hospital consents,procedure,identified proper surgery part by marking the site and everyone agrees that they have the correct patient, the correct site, the correct procedure, the correct consent etc.
In addition, the hospital needs to look at its system process and not soley concentrate on individuals pertaining to the surgery department. Prevention strategies for wrong-site surgery events begin from the admission process and continue throughout the patient’s stay. Every hospital is vulnerable to a never event and must ensure that performance improvement strategies like root cause analysis, a system review and other PI methodologies are held on near misses
to catch the system process error before it reaches the status of a never event.
Sandra Stanley RN
Clinical Safety Specialist
feshion | Apr 28, 2012 | Reply
well, this is really a nice post.I really like the way you start and conclude your thoughts. Thank you so much for this information. keep posting such good stuff