Media Release

Immediate Release
Date: August 2, 2007

CORRECTION

HEALTH to Review Neurosurgery Practices at Rhode Island Hospital

Today the Rhode Island Department of Health (HEALTH) issued a compliance order to Rhode Island Hospital that will require the facility to hire an independent quality consultant to review and monitor its neurosurgery practices, as a result of the hospital's third wrong site surgery in six years. (The compliance order is available at the following link on HEALTH's website: www.health.ri.gov/hsr/facilities/hospitals/Compliance_Order_RIH_RESTORED.pdf)

HEALTH's action was in response to notification from Rhode Island Hospital on July 31 of a wrong site/side surgery for treatment of a subdural hematoma (blood between the brain and the skull). This incident indicates a pattern of wrong site/side surgery at Rhode Island Hospital dating back to 2001 , involving at least three separate neurosurgical procedures and different physicians. Hospitals are required to report such events to HEALTH within 24 hours.

“The system currently in place at Rhode Island Hospital for ensuring appropriate surgery has failed”, said Director of Health, David R. Gifford, MD, MPH. “We therefore are requiring the hospital to take immediate steps to prevent this from happening again. We also will be looking closely not only at all the health professionals involved, but at the neurosurgery program as whole and hospital systems around patient safety.”

These events underscore how important it is for patients to review surgery plans and consent forms with surgeons before undergoing any type of surgery. HEALTH believes that these safeguards will improve patient safety. More patient tips can be found on the Joint Commission's website at www.jointcommission.org/PatientSafety/UniversalProtocol/wss_tips.htm

Effective immediately, the hospital is required to have a second physician verify surgery plans to ensure that they are performed on the correct side of the patient. Also as part of the compliance order, HEALTH will monitor the facility; its plan of action to correct their deficiencies in the practice of neurosurgery; and the hospital's work with the outside consultant.

The operating surgeon has voluntarily agreed not to perform surgeries while the compliance order is in effect and the investigation is ongoing. (The consent order for the physician can be found at www.health.ri.gov/hsr/bmld/actions/harrington_jfrederick.pdf). HEALTH's Board of Medical Licensure and Discipline and Board of Nursing will also investigate whether any disciplinary action should be taken against the other healthcare professionals involved, including supervisors, since we have detected a pattern.

The Joint Commission tracks wrong site surgery as a voluntarily reported event in its sentinel event database. It is the most frequently reported sentinel event in the database. Since 1996, there have been 550 reports, yet it is viewed as an event that is often under reported. In 2004, the Joint Commission launched a Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. All Joint Commission accredited institutions are required to follow the protocol. Part of HEALTH's investigation will include looking at how well Rhode Island Hospital is complying with the protocol.

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