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Department of Health Issues Compliance Order to Rhode Island Hospital

On October 22, Rhode Island Hospital (RIH) notified Rhode Island Department of Health (HEALTH) of a wrong-site procedure in the operating room. A patient was scheduled for elective surgery on two different fingers of the right hand. Both procedures were performed on the same finger.

HEALTH discovered several problems in the hospital’s surgical program including failure of the surgeon to mark the fingers. In addition, after notifying the family of the error and going back to do surgery on the correct finger, they failed to conduct a time out. They also failed to implement the uniform state-wide policy adopted by all other hospitals. A detailed description of the findings from the inspection can be found in the deficiency report (see http://www.health.ri.gov/discipline/hospitals/RhodeIsland200911.pdf).

In response to the deficiencies, RIH received an immediate compliance order on October 26 requiring every surgery at RIH to be observed by a licensed clinical professional (not part of the surgery team) who is trained to observe surgical site markings and time out procedures. Today’s amended immediate compliance order outlines additional conditions RIH must meet and fines the hospital $150,000.

“Rhode Island Hospital’s decision to not follow recently established state wide protocols designed to prevent medical errors is of grave concern,” said Director of Health David R. Gifford, MD, MPH. “What is even more disturbing is that after the surgical team realized they had made a mistake and received permission from the family to perform the originally scheduled procedure, they did not do a time out. This pattern of surgical errors is completely unacceptable and must be corrected to protect the safety of all patients at the hospital.”

The hospital received a compliance order that requires them to: · Continue clinical observation of surgical-site marking and time out procedures for at least one year. · Immediately adopt and implement into practice the Rhode Island Uniform Surgical Safety Checklist and Standard Definition. · Shut down elective surgery for one day and conduct a mandatory training and review of the uniform surgical procedures with all surgical staff. · Install video and audio monitoring equipment in each operating room.

Other conditions are described in the full compliance order. (see http://www.health.ri.gov/discipline/hospitals/RhodeIsland200911.pdf)

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