Projo 7 to 7 News Blog

In the case of mouth surgery, said Health Director David R. Gifford, the site cannot be marked, so the surgical team was exempt from that step -- but no one had developed alternative ways, such as marking the cheek, to ensure the correct side is cut.

The Health Department's preliminary findings in its investigation of Monday's incident identified numerous problems, including failure to follow hospital policies, inconsistent interpretation of policies, and inadequate assessment and training. But Gifford said that it's not clear to what extent the procedural flaws actually contributed to Monday's error.

Indeed, what happened Monday during surgery to correct a cleft palate remains a puzzle.

"I don't think anyone will ever know what exactly went wrong in this case," Gifford said.

According to Gifford, the surgery involved removing a small piece of bone from the hip and placing it in the roof of the mouth. The child had already had the left side of the mouth repaired, and the team was supposed to work on the right. The consent form that the parents had signed was clear and correctly done. The team also properly performed the "time out," with everyone agreeing that they would work on the right side. Nevertheless, the surgeon cut into the left side.

A resident -- a doctor in training -- who had been harvesting the bone from the hip noticed that the surgeon was working on the wrong side. The surgeon stopped and then performed the surgery correctly on the right side. The hospital said that the child did well and was discharged without complications.

Gifford said the resident's willingness to challenge a supervisor is a sign of an improved "culture" at the hospital.

"The hospital clearly has made progress from before," Gifford said, "but there needs to be more done."

Murphy, the hospital vice president, declined to discuss details of Monday's surgery but noted, "Since this was intra-oral surgery, particularly in a child, the ability for everyone in the room to see what was happening in the case was curtailed." He also said the operation was "a unique situation that presented characteristics that we had not dealt with before." He declined to elaborate, saying he did not want to take a chance of identifying the patient.

"We have written and rewritten [our policies] many times to try to accommodate all the different situations that come up," Murphy added. "We haven't anticipated the millions or billions of situations that may come up."

Murphy said he was pleased with the "very thoughtful way" the hospital and the Department of Health worked together on addressing the issue.

"We both have the same goal," he said. "We want to make the care at Rhode Island Hospital ... as safe as possible."

Under Friday's consent agreement, the hospital will take four actions. In addition to the meetings to review pre-surgery procedures, the hospital will to contract with a patient-safety consultant to establish a system for reporting "near misses" --mistakes that almost happen, which can foreshadow future problems. The hospital will also develop methods to regularly confirm that all surgical staff members understand the current policies and procedures. And it will clarify and standardize its "time out" procedure, in which the surgical team pauses before surgery to make sure that it's about to perform the right procedure on the right part of the right patient.

Gifford said the Health Department's investigation of the hospital is still under way. At the same time, the surgeon -- whom the hospital has put on administrative leave but would not identify -- has been referred to the medical licensing board for possible disciplinary action. The nurses and the rest of the surgical team have been exonerated. Murphy would not say what type of surgeon was involved except that the person was not an oral surgeon. Gifford said he didn't know the specialty.

"It is clear that the hospital needs to be more diligent about assuring consistent implementation of patient safety standards," Gifford said in a statement, "and continuously evaluating and improving their policy based on feedback from staff who are using the policy."

Dr. Timothy J. Babineau, hospital president, said in a statement: "We have been working diligently to learn from the error that occurred... We apologized to the patient and the family and realize that this error should not have happened. We have come together as a hospital, a system and a state to prevent this from happening in the future."

The original version of this story was posted at 2:11 p.m.