Hospital Repeats Wrong-Sided Brain Surgery

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.

"There are a number of activities in place to ensure that the patients in the OR [operating room] are safe, and that we do not have any more outcomes like this in the future," she said.

But in this case at least, the measures seem not to have worked. Lifespan spokesperson Gail Carvelli says the most recent error occurred during a bedside procedure -- one that does not take place in the operating room. Hence, she adds, a new measure that offers another level of monitoring for these types of procedures will now be put into place.

But the fact that the errors are not restricted to one area of the hospital has some worried.

"Different people each time, different areas of the hospital -- we are really concerned [that] they put checks and balances in place in the hospital," Gifford said.

Uncommon, but Serious

Fortunately, wrong-site surgery affects only a very small percentage of operations in the United States every year. But considering the sheer number of surgeries in which sidedness is a factor, even this small ratio translates into thousands of cases.

A study published in the April 2006 issue of the journal Archives of Surgery estimates that wrong-side surgeries occur between 1,300 and 2,700 times a year in the United States.

Doug McCoy has firsthand experience with one such procedure. Doctors were supposed to remove a benign tumor from his right ear. Instead, they operated on McCoy's left ear, causing him to temporarily lose hearing in that ear.

"You've got 50-50 chances," McCoy told 'Good Morning America.' "It's not rocket science."

And in some instances, the consequences can be far graver than temporary hearing loss. In the July event at Rhode Island Hospital, an 86-year-old man died a few weeks after a brain surgery in which the doctor operated on the wrong side of his head.

Investigators have still not released a conclusion as to whether or not the mistake was responsible for the man's death. But doctors say it's an error that should never have happened.

"The surgeon, although he had seen a CAT scan in advance, misremembered the side of the surgery," Dr. Robert Crausman of the Rhode Island Department of Health told "Good Morning America." "Part of the picture here is an operator error."

How Patients Can Protect Themselves

So what can patients do to minimize the chance of finding themselves on the receiving end of a wrong-sided surgery? Unfortunately, physicians said, not much.

But Dr. Christine Ren, an associate professor of surgery at the New York University School of Medicine, said that patients should take the initiative when possible to minimize the chance of a wrong-sided error.

"If you are about the have a certain-sided surgery, make sure to meet with the surgeon the day before the surgery to reiterate what you're having done and on which side," she said. "Always double check, and don't be afraid to ask questions."