On Monday, the Rhode Island State Department of Health issued a reprimand and $50,000 fine to a hospital after its third incident this year of a doctor performing brain surgery in the wrong side of a patient's head.
"We are extremely concerned about this continuing pattern," Director of Health David R. Gifford said in a written statement. "While the hospital has made improvements in the operating room, they have not extended these changes to the rest of the hospital."
According to the health department, the most recent occurrence was on Friday when the chief resident began to perform brain surgery on the wrong side of an 82-year-old patient's head. The patient has been reported as being okay.
A previous incident which happened in February, involved a different doctor who performed neurosurgery on the wrong side of another patient's head, said Andrea Bagnall-Degos, a health department spokeswoman. That patient was also reported as being okay, she said.
However, in August, a patient died a few weeks after yet another doctor performed brain surgery on the wrong side of the patient’s head. It was that particular surgery that encouraged the state to order the hospital to take a series of steps to ensure such a mistake would not happen again, including an independent review of its neurosurgery practices and more thorough verification from doctors regarding surgery plans.
In a written statement, Rhode Island Hospital said it was working with the State Department of Health to minimize the potential risk of medical errors.
"We are committed to continuing to evaluate and implement changes to our policies to help ensure these human errors are caught before they reach the patient," the statement read.
The hospital stated that it’s re-evaluating its training and policies, providing more supervisory oversight, giving nursing staff the authority to enforce proper procedures, as well as other steps.
In addition to the fine, the Department of Health has ordered the hospital to develop a neurosurgery checklist that includes information about the location of the surgery and a patient's medical history. The state also ordered the hospital to implement a plan to train staff on the new checklist.
The Board of Nursing and Board of Medical Licensure and Discipline are also investigating the incident.