In August, a woman in her 60s had an operation at Rhode Island Hospital to remove a brain tumor. The next day, an MRI revealed the piece of metal and it was safely removed, according to news reports.
The incident, which cost the hospital a $300,000 fine — the largest ever for the Ocean State — made news the same day the hospital revealed another “never event:” A surgical instrument was left in the abdomen of a patient for three months, only to be discovered Oct. 15.
The hospital’s safety protocols for brain surgery call for X-ray examinations to make sure nothing is left behind, but an examination by the R.I. Health Dept. found that the surgical team never discussed an X-ray scan.
“They were aware drill bit had broken off and they each presumed it had been accounted for,” said Dr. John Murphy, vice president of medical affairs and chief medical officer of the hospital, according to the Providence Journal.
David Gifford, director of the state’s health department, said the MRI that revealed the drill bit in the patient’s skull put her “at significant risk of harm” because the magnetic scan could have shifted the broken piece of metal, the newspaper reported.
The incident prompted the Centers for Medicare & Medicaid Services to order a soup-to-nuts inspection of the hospital, only the second such action at a hospital in Rhode Island, according to the ProJo.
In the second incident, an unrelated imaging test detected the instrument left behind in the patient’s abdomen, three months after the July 13 surgery. Little else is known about the incident, which is still under investigation.
It’s not the first time the hospital has committed a never event, which Gifford called a “troubling pattern.” The hospital failed to respond to numerous reports of inaccurate counts of surgical instruments and failed to act after receiving reports of an anesthesiologist with the habit of not wearing a surgical mask in the operating room, according to the newspaper.
In October 2009, a surgeon at Rhode Island Hospital operated on the wrong finger joint, the fifth wrong-site surgery at the hospital in about three years, the ProJo reported. The R.I. Health Dept. fined the hospital $150,000 and ordered it to hire a consultant to observe surgery for three years, shut down surgery for one day and conduct mandatory training on surgical procedures and install audio- and video-monitoring equipment in the operating rooms for periodic observation.
“They’ve got to figure out how to get the staff to follow the policies,” Gifford told the newspaper.
Surgeries on the wrong body part — or even the wrong patient are a persistent problem, according to a recent study published in the Annals of Surgery. Researchers examined 27,370 adverse event reports for that time, looking for so-called “never events” — medical errors that are never supposed to happen, like operating on the wrong patient or body part. There were 25 wrong-patient and 107 wrong-site operations during the six-year span between 2002 and 2008 in Colorado.
Several companies are working systems to reduce the chance of instruments or other items behind left behind in patients’ bodies after surgery. ClearCount Medical Solutions Inc., which closed a $5 million Series B funding round in August, is developing the SmartSponge and SmartWand systems. They use radio-frequency identification technology and chips embedded in sponges to allow surgeons and nurses to detect and count sponges during surgeries.
