Hospital Repeats Wrong-Sided Brain Surgery

The most recent mistake occured despite measures taken after two similar errors.

ByABC News
November 28, 2007, 1:38 PM

Nov. 28, 2007— -- For the third time this year, doctors at Rhode Island Hospital have operated on the wrong side of a patient's head -- an action that has brought about censure from the state Department of Health and a $50,000 fine.

The episode has also prompted many to ask how such a mistake could repeat itself three times in the same year -- and four times over the past six years.

The most recent incident occurred Friday, Nov. 23. An 82-year-old woman, whose name has not been released, required an operation to stop bleeding between her brain and her skull.

"They started the operation on the wrong side [and] figured out that they were operating on the wrong side before they got too far into the operation," Dr. David Gifford of the Rhode Island Department of Health told "Good Morning America" today. He added that after closing the incisions created on the wrong side of the patient's head, they were able to continue the operation on the correct side and remove a dangerous clot.

"My understanding is that the patient was OK at the time," he said.

Officials at Lifespan Corp., the company that runs the hospital, refused interview requests. The hospital instead issued a statement that indicated it would strengthen oversight procedures and that "corrective action and counseling have occurred with all the individuals involved."

But the statement outlines plans that are reminiscent of corrective measures outlined by Dr. Mary Reich Cooper, vice president and chief quality officer for Lifespan, in a Nov. 2, interview with ABCNEWS.com.

During the interview, Cooper said the first two neurosurgery mistakes -- one in February and one in July -- had led to the implementation of a number of safeguards at Rhode Island Hospital to prevent such mistakes from happening again.

She said these measures included more continuity in the transmission of patient information between departments, additional availability of patient records during surgery, a policy directing a second physician review of the proper site and side for all surgical cases before surgery, and the presence of monitors to eliminate potential sources of medical error.