Update: Hasbro surgeon operates on child's wrong site
6:17 PM Wed, May 13, 2009 | Permalink
Email
 |
 |
Projo 7 to 7 News BlogTaking the news pulse of Rhode Island and Southeastern Massachusetts, by Providence Journal and projo.com staff, from 7 to 7, every business day |
|
Get the 7 to 7 on your mobile at www.projo.com. Twitter: projo | RSS | Email alerts
« Reed, Whitehouse back Neronha for U.S. Attorney post |
Main
| Senate health panel endorses state human services chief »
A surgeon on Monday began operating on the wrong part of a child's mouth during oral surgery at Hasbro Children's Hospital, the fifth wrong-site surgery to occur at a Lifespan hospital in the past two years. The error was noticed during surgery and "the team was able to perform the correct procedure with good results," said a statement from Dr. Timothy J. Babineau, president of Rhode Island Hospital, which Hasbro is part of. "The patient is in good condition and we do not anticipate any further complications related to this error." The hospital apologized to the patient and the family. It also placed the surgeon and the surgical team on administrative leave after a preliminary investigation found that "at least one of our standard policies was not followed," Babineau said. The state Health Department, notified of the error late Monday, sent a half-dozen inspectors from its facilities regulation division and the medical and nursing licensing boards to Rhode Island Hospital on Tuesday and Wednesday. They have been interviewing the staff and looking over the operating room to pinpoint the cause of the error and to advise the health director on whether to take disciplinary action. Health Director David R. Gifford said he doesn't expect a simple answer: "As in all of these cases, it's never one individual, nor is it ever one isolated event." Gifford said that Monday's oral surgery involved one side of the roof of the child's mouth, and the team initially started working on the wrong side. He said the patient was a "young child" between the ages of 5 and 15. "This is an event that should absolutely never happen. There just is absolutely no excuse for it happening," said Dr. Mark R. Chassin, president of the Joint Commission, the national organization that accredits hospitals and other health-care institutions. Hospitals around the country reported 116 wrong-site surgeries last year, making it the most common of the "sentinel events" -- severe, dangerous errors -- that are tracked by the Joint Commission. "The vast majority these events are not the fault of people, they are the fault of processes that don't work," Chassin said in an interview Wednesday. "The state of our art and science in health care, unfortunately, is that we don't know how to perfect these processes yet to guarantee that it never happens." Hospitals are supposed to have systems in place, such as checklists, "time outs" before surgery and multiple layers of verification, to catch human errors before they are carried out. The problem, Chassin said, is that the safeguards have become an added layer of administrative chores that time-pressed health professionals are apt to perform by rote. Now, patient-safety experts are looking at ways to integrate safety protocols into the flow of clinical care. In fact, the Joint Commission plans to work with hospitals in Rhode Island to develop and test some of these new processes, Chassin said. In three instances in 2007 at Rhode Island Hospital, doctors intending to drain blood that had pooled inside a patient's skull drilled into the wrong side of the head. The Health Department fined the hospital $50,000 and suspended a surgeon. The hospital replaced its chief of neurosurgery and hired outside experts to review its safety procedures. In 2008, Miriam Hospital, which is also part of the Lifespan hospital group, operated on the wrong knee of a patient undergoing arthroscopic surgery. The Health Department reprimanded the hospital, the surgeon and two nurses. Both Miriam and Rhode Island are part of the Lifespan hospital group. Asked why these problems keep recurring, despite efforts to prevent them, Gifford said, "We are asking ourselves that a number of times over here. Both hospitals have made some progress but clearly not enough." But Gifford said that safety measures that seem simple -- left or right? -- can be complicated to carry out. For example, the surgical team is supposed to mark the spot where surgery should take place. But, he said, "How do you mark inside the mouth? The standard policy is silent on stuff in the mouth. It doesn't need to be marked." He also speculated that there may be a culture of "it couldn't happen to me" that is hard to break down. Gifford noted that wrong-site surgeries probably occur with equal frequency in other states but may not get the same level of attention. "Both the hospitals and the Health Department are making it a priority to publicize them because that's how we're going to change the culture," Gifford said. Meanwhile, hospitals around the state have teamed up to standardize the marking of surgical sites, so that the many surgeons who practice at more than one hospital will have consistent rules. Additionally, under a new state law intended to reduce medical errors, the state's first "patient safety organization" has been certified. The group, a private company from Pennsylvania, will analyze data from hospitals to identify ways to improve safety. "The hospitals that are working on this problem are serious about getting rid of it," said Chassin, of the Joint Commission. "This is not a problem of lack of will, lack of interest or lack of attention. We don't have the tools yet to be able to guarantee that events like this, which should never happen, literally don't ever happen." This entry was first posted at 10:36 a.m. and updated at 1:46 p.m. 
CommentsLeave a commentPlease be civil. Vicious comments, personal attacks and profanity won't be published. Name and email are required; email address will not publish. |
Tags 
New comments
New photos
New posts
Projo blogs
Archives
Isnt the check list and and procedures there to stop things like this from happening i mean mistakes happen! Paid pro's still cant follow a check list! They should be put on leave, and so thankfull nothing serious happened.
Report Abuse
You've got to be kidding me. Does the Board of Lifespan have any idea what is going on in these facilities? You have some of the highest paid administrators in the nation yet they can't get this very important problem fixed. When are we going to see new leadership at these institutions? How many more wrong side surgeries do you need or are we waiting for someone to get killed first? Check around, no other system or hospital network in the country has a record as bad as Lifespan's and it's due to the culture that has been instituted by senior leadership, which is one of fear and retaliation if you point out something wrong.
Report Abuse
Here we go again. Why can't they get it right? As patients, we trust our doctors and surgeons to be competent to perform their duties. Do we need to worry every time we or a loved one has surgery?
Don't we have enough on our minds? Pay attention doctors and nurses, that's your job!!!!!
Report Abuse
Now, answer me this.....
Do they still have to pay for the services?
Report Abuse
I realize the above story is not complete and there are facts missing (what procedure was in performing in error)?
But, how can a doctor look inside a child's mouth that has a cleft palate and not realize what he was there to do? (Hey look, there is a hole in the roof of a kid's mouth)? Hello?
As far as the "time out" that is called before a procedure is to start..I was at another hospital for a colonoscopy and the nurse called "TIME OUT"..she read the info she was suppose to, but no one in the room listened except me. The doctor walked out of the room during this drill. I mentioned it to the nurse who called the time out and again when the hospital called the next day to see how I was.
A different routine needs to be established.
Hope the child has not after effects of the error.
Report Abuse
Bottom line to all of your comments...this Dr is a HUMAN BEING first then a professional! I am sure the Dr. does not wake up each operating day and say who can I screw up on today? The Dr. has to live with this for the rest of his/or her life and I am sure that although the Dr. is greatful that no harm has come to this patient the horror of it all does not end there.
Report Abuse
Massachusetts had 24 wrong side surgeries last year alone. It occurs all over the country. I agree it shouldnt happen at all - but obviously it is not a Lifespan issue, its an issue for the industry as a whole.
Rhode Island is fortunate to have all of the Lifespan hospitals, they all bring advanced expertise and medical practices to the state.
Report Abuse
I'm amazed each and every time I hear a story like this. It takes me back to December, 2000 when not only the wrong surgery was performed at Hasbro, but on the wrong patient. Rules and guildlines are implemented so these mistakes DO NOT happen. Please pay more attention when you have someones life in your hands. They say the patient is in "good condition" and do not anticipate any further complications. The child may appear well on the outside yet, no one see they invisible scars that are left behind on the child do to this mishap. My thought and prays are with the child and family.
Report Abuse
My sincere sympathies to the poor kid.
And how much does this guy make?
Whatever happened to checklists? Did he even see the patient prior to the surgery? Was he distracted by the good looking nurse standing next to him? Was the good looking nurse standing next to him distracted by his attention towards her? Was his degree from a reputable medical school or a fly by night in Mexico?
Questions, I have questions. Good thing it wasn't a colonoscopy.
Report Abuse
You mark the cheek, Dr. Gifford - or you mark the arm....
These "time out" procedures are ignored. The parent must be given broad range of accompanying a child as far into the OR as possible to prevent such an occurance. As a parent who has been there, I insisted upon it. The squeaky wheel at least gets attention. Awful thing to have happened. Isn't it enough now to require a higher level of review - what IS the real problem here?
Report Abuse
Before you assume the worst about people, please make sure you yourself are well-informed.
Cleft palates are not always obvious. They can involved only the internal structures, such as bone. In some cases, they may be partial or subtle, or on both sides -- and the decision may be made to operate on one side first or one side only. For someone looking in from the outside, these events are obvious. But when you have 200 obvious things to keep track of, especially when they're not as "obvious" as everyone assumes, things get missed because surgeons are human too. What we need are better safeguards and systems from the government and administration -- ones that are not just bureaucracy that hampers doctors' jobs (like the systems in place right now), and actually work.
Report Abuse
My sincerest sympathy to the parents and the child, but let's not forget that doctors are human beings and not some kind of machine. They corrected the problem with minimal damage to the patient and did the unheard of - apologized. When taken in context of the number of surgical and other procedures performed on a daily basis, emergent and elective, the number of mistakes is miniscule. There are procedures in place to prevent accidents, but no method is perfect.
Worse mistakes that this happen every day in hospitals all over the world. I just read about a patient in New York that was prepped for brain surgery, her doctor canceled at the last second for a "family emergency" that was later found out not to exist and another physician refused to perform the surgery because "she is not my patient". Then there was the doc in MA who walked out of the OR with a patient on the table to take care of a child support check! Those are 2 that have come to the public eye.
Report Abuse
Thank you, everyone who realizes that doctors are humans too. Surgeons have to deal with more complex issues with bigger consequences than just about any other profession, and therefore we need systems to help us prevent mistakes. If you look at the history of modern medicine though, our systems are still pretty young and primitive. You cannot compare surgery to flying planes; surgery is a thousand times more complex and harder to define.
This child had a birth defect, and was not harmed by the mistake -- he will still come out much better than if no one (like this surgeon) cared. That does not excuse the mistake, but that's information for those of you wishing the child well.
In response to the person asking how much this surgeon makes, and whether he was looking at the pretty nurses -- first that's a chauvinistic remark. Secondly, this surgeon could have easily chosen a career doing cosmetic surgery, with the kind of training he had. He chose to help children with birth defects instead. Lastly, surgeons go through at least 16 years of education and training after high school, during which time they make nothing or nearly nothing and rack up educational debts on the order of a quarter to a half million dollars. Then they work 100+ hours a week for the salary they finally make. Let's cut the guy some slack and sit down constructively to solve the problems at hand.
Report Abuse
I worry that "reason" is missing the whole point. The reason checklists are needed and following them imperative is simply because cleft palates, like many surgical conditions, may be un-obvious to the eye. We are all human, we all do make mistakes, we therefor need to create backup systems to prevent these mistakes. Once these systems are created they need to be implemented. This implementation has obviously failed at Lifespan. "Concerned" is correct to call this a failure of senior management: systems and procedures are in place and yet they are consistently ignored. I worry that "pm's" experience - where the time out was ignored by the physician may be more the norm than the exception. As for Denise's comment that Lifespan brings advance expertise (is there expertise that is not advanced?) and medical practice to the state I have to worry about the condition of the other hospitals in the state if that is the case. We should not have to follow our children (spouses,parents or friends)into the OR: the hospitals MUST enforce safe practice policies. The reason airlines follow checklists is obvious: everyone goes down with the plane. The reason hospital are more cavlier about checklists: only the patient is physically harmed by an error. Please step up to the plate Mr Verrechia: if your hospitals will not follow the rules without negative consequences then I perhaps it is time for you to institute some.
Report Abuse