On August 9, 2010, the Department of Health (HEALTH) received notification from Rhode Island Hospital that during a neurosurgery procedure at RIH on August 4, 2010, a piece of a broken drill bit was left in the patient’s skull after the surgery was completed.
HEALTH conducted a joint investigation with the Center for Medicare & Medicaid Services (CMS) and discovered that the hospital is not actively ensuring that the operating room staff is following existing hospital policy. RIH’s surgical count policy states that if a surgical tool or device is unaccounted for at the end of surgery, an x-ray of the patient should be done before the patient leaves the operating room to assure that the tool or device is not inside the patient. In this incident, no x-ray was taken and the surgical count was documented as correct. (To view HEALTH’s statement of deficiencies of the incident, visit http://www.health.ri.gov/discipline/hospitals/RhodeIslandFindings201010.pdf)
HEALTH also found that numerous staff reports of incorrect surgical counts have gone unanswered by the hospital. Similarly, reports from nursing staff that an anesthesiologist did not wear a surgical mask in the operating room were not addressed by medical leadership.
Due to RIH’s failure to follow established policy and failure to adequately address staff reports of problems that could result in medical errors, HEALTH is fining Rhode Island Hospital $300,000. In addition, CMS has asked HEALTH to conduct a full survey of all areas of the hospital and to ensure that the hospital is in compliance with all of the Conditions for Participation for Medicare. (To view the letter to the hospital from CMS and the CMS statement of deficiencies, visit http://www.health.ri.gov/discipline/hospitals/RhodeIslandFederalFindings201010.pdf) Two physicians and one nurse are being referred to their licensing boards for review.
“There is a troubling pattern of disregard for established policies that are designed to protect patient safety and prevent medical errors in Rhode Island Hospital’s operating rooms,” said Director of Health David R. Gifford, MD, MPH. “When reports from staff about problems in the operating rooms are not adequately addressed, employees are less likely to speak up and report potential problems or concerns.”
RIH must submit a plan of correction to HEALTH by November 10, 2010, and must pay the fine by November 24, 2010.