Projo 7 to 7 News Blog

By Felice J. Freyer
Journal Medical Writer

The Health Department has reprimanded the Miriam Hospital after identifying a confluence of missteps that led a surgical team to operate on the wrong knee last month.

The problems included marking surgical sites with ink that sometimes washes off and failing to verify the site against the original source of information.

But Dr. David R. Gifford, health director, said an underlying issue was the hospital's "culture"-- a failure to appreciate the importance of patient-safety measures. For example, on a pre-surgical checklist, a nurse drew a vertical line through several boxes rather than checking off each individually.

In a consent agreement signed yesterday, the hospital pledged to make several changes in policy and procedure and to hire a patient-safety consultant.

"We need to do the technical fixes," Gifford said. "I'm [also] trying to get at the underlying culture."

"It's not that Miriam doesn't have a culture of safety," said Dr. Kathleen Hittner, hospital president. "Of course we have a culture of safety." The nurse who drew the line through the boxes may have diligently checked each item, but just filled the form quickly, because there are so many forms, she said.

The culture change that's needed, Hittner said, involves making sure that "people speak up and tell us what is going." For example, no one informed the hospital administration that the pens used to mark surgical sites sometimes blurred during preparation for surgery.

"We have a very hard-working dedicated staff," Hittner added. "We have great people here who do a wonderful job. I'm very proud them."

Meanwhile, after learning of the Health Department's findings, the U.S. Centers for Medicare and Medicaid Services has notified Miriam that it is "not in compliance" with requirements to participate in the federal program and that the deficiencies are "of such a serious nature as to substantially limit your hospital's capacity to render adequate care."

CMS, which has lately taken a hard line against medical errors, has hired the Health Department to conduct a top-to-bottom survey of the hospital and required it to correct any deficiencies before its standing with Medicare can be restored.

Gifford said that the on-site portion of that survey is being completed today, and that there was no reason to think that Miriam would lose its right to accept Medicare patients.

The incident occurred on Sept. 19, when a 60-year-old came to the hospital's outpatient surgical center for arthroscopic surgery on the knee to treat arthritis and a meniscal tear. Shortly before surgery, the surgeon met with the patient, discussed the surgery, and correctly marked her left knee with the word "yes."

Then, a nurse mistakenly placed a tourniquet on the wrong knee, and the wrong knee was prepped for surgery. In the operating room, the surgical team performed the required "time-out" and went down a checklist of items, but failed to make sure that they were about to operate on the correct knee.

The error was first discovered by the patient when she awakened from surgery. At the patient's request, the hospital then performed the surgery on the other knee.

The Board of Medical Licensure and Discipline and the Board of Nursing are investigating whether to take disciplinary action against any of the professionals involved.

 Tags  health department Miriam Hospital

Comments

Dan said:

Does this mean that Miriam and the physicians who got it wrong will not be billing the patient or his healthcare provider? After all, this kind of screw up should be eaten by those who committed this unexcusable error. If they bill, they should be charged with fraud.

Link | October 10, 2008 9:05 PM
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Jim Traffic said:

what a joke.

Link | February 18, 2009 11:29 AM
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