Few people could argue with the notion that hospital operations performed on the wrong body part are events that should never happen, but at one hospital, these so-called wrong-site operations have taken place five times since 2007.
Rhode Island Hospital, based in Providence, has been fined $150,000 by the Rhode Island Department of Health after a surgeon operated on the wrong finger of a patient last month. Among the ramifications, the hospital will have to install video cameras in all of its operating rooms and all surgeries will have to be watched by a clinical professional, not on the surgical team, trained in surgical safety measures.
Rhode Island Hospital previously drew scrutiny in 2007, after three separate brain surgeries were done in the wrong locations. While the hospital said it would make reforms at the time, some see the errors that have happened since then as a sign that the hospital has not followed through.
Earlier this year, a surgeon operated on the wrong side of the mouth of a patient with a cleft palate.
"We have been looking into this for quite a while," said Dr. Sidney Wolfe, president of the consumer advocacy group Public Citizen. "This is now deemed inexcusable, it's a 'never to happen' occurrence in a hospital. When it repeatedly happens in a hospital, it means a system isn't in place in the hospital to keep it from happening."
Lifespan Corp., which owns Rhode Island Hospital, sent ABC News a statement, but declined to comment for the story.
"At Rhode Island Hospital, we remain more committed than ever to working on methods to reduce the incidence of all medical errors from reaching patients," said hospital president and chief executive officer Dr. Timothy Babineau in the statement. "Patient safety has always been, and remains, our number one priority."
An analysis of patient safety from HealthGrades, which ranks hospital quality, showed Rhode Island Hospital performed average in its overall patient safety.
Will Fixes Improve Safety?
The installation of video cameras is among the more unconventional measures being taken by the state, but questions remain about how effective they will be.
Dr. Glenn Rothman, chair of surgery for Banner Desert Medical Center in Mesa, Ariz., said cameras will likely do little to stop errors like the one in this case.
"I'm not aware of any data that show that works," he said. "Would cameras in the cockpits of planes reduce pilot error?"
Nancy Foster, vice president of quality and patient safety policy for the American Hospital Association, had a similar sentiment, saying cameras could be helpful, but would not prevent surgeries in the wrong places.
"They are not used to prevent the error that is occurring at that moment," she said of cameras, comparing them instead to black boxes on airplanes. "It may not be able to prevent a crash but it is a valuable tool to prevent a similar problem from occurring [in the future]."
Never Say Never?
Foster was reluctant to say that "never to happen" occurrences like surgery in the wrong place could really be made to never happen.
"That was a catchy phrase. I'm not sure [the Centers for Medicare and Medicaid Services] really thought we had the knowledge and the tools to ensure these events never happen," she said. "I hate to say never. I think they can be made so rare as to be virtually eliminated. I don't think we have all the knowledge and the tools right now to make that happen."
Wolfe blames the culture of the hospital for not taking these errors seriously enough and not doing enough to stop the wrong-site incidents, since he said no one person could be blamed for these errors, given the number of people involved.
"The hospital has failed repeatedly to succeed in stopping this," he said. "Most hospitals in the country, in the course of a few years, don't have any, or at most, one wrong-site surgery. It'll get fixed, but I would have said that when I saw the story two years ago."
Kristina Fiore of MedPageToday contributed reporting.