Repeated wrong-site surgeries? Let's go to the videotape!

Within the past two years, Rhode Island Hospital has seen five cases of wrong-site surgery, a serious situation that has gotten the facility in deep water with the state's Department of Health.

The errors have involved a wide variety of procedures. In 2007, for example, the hospital was fined $50,000 for errors in brain surgeries performed on three different patients, and was reprimanded for mistakes in a cleft palate procedure last May. The most recent issue, involving a hand surgery gone wrong, seems to have been the final straw for regulators, who reported that the hand surgery team failed to conduct a mandatory "time out" to between procedures to double-check their plans.

In response to these problems, the hospital is now required to spend $150,000 to install video cameras in all of its operating rooms within 45 days. Each doctor performing surgery must be taped a minimum of twice per year.

The state also demands that every surgery at the Providence-based hospital be observed by a clinical professional who isn't part of the surgery team and has expertise in surgical site markings and time-out methods. In addition, the hospital must immediately adopt the state's Uniform Surgical Safety Checklist and Standard Definition.

Furthermore, the hospital will be required to cease elective surgeries for a day in order to conduct mandatory training and reviews of the uniform surgical procedures with all related staff.

To learn more about this issue:
- read this MedPage Today piece

Related Articles:
Another wrong-site surgery reported at Rhode Island Hospital
Study: Wrong-site surgeries, close calls common
Study: Pre-op briefing can lower surgical error rates

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