Hospital says Surgeon opens up wrong side of man's head

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Hospital Says Surgeon Opened Wrong Side of Patient's Head; CT Scan Was Displayed Backward

PROVIDENCE, R.I. (AP) - A surgeon at Rhode Island Hospital operated on the wrong side of a man's head after a CT scan was placed backward on an X-ray viewing box, the hospital told the state Department of Health.

The patient had bleeding on the right side of his brain, but the reversed scan made it look as if the bleeding was on the left, according to the hospital's report filed Tuesday. In addition, the patient's incision site had not been marked with a pen, as recommended by error-prevention experts.

After the surgeon drilled two holes in the left side of the patient's skull and found no bleeding, the procedure was repeated on the right side and the blood was drained. The patient has suffered no ill effects from the Dec. 12 error, hospital spokeswoman Jane Bruno told The Providence Journal.

Wrong-site surgery tops a list of 27 serious, preventable events prepared by the National Quality Forum, a Washington-based group that promotes a national strategy for measuring health-care quality.

Dr. Kenneth Kaizer, the group's president, said such surgery "occurs more frequently than a lot of people would like to believe."

"With humans, there's always going to be error," he said. "That's why we need to design systems and processes to minimize error."

The Department of Health has cited the hospital for not following all aspects of its own policy requiring multiple verifications of a patient's identity and the site of surgery.

The professionals involved in the operation - the surgeon, two surgical residents, the operating-room nurse, the operating-room technologist, and the certified registered nurse anesthetist - have been referred to their licensing boards for investigation, said Wayne I. Farrington, chief of the Health Department's division of facilities regulation. Their names were not released.

"The public puts an enormous amount of trust in our institution and we really take that very seriously. We do deeply regret that this incident occurred," Bruno said.

The error occurred one year after another mix-up at Rhode Island Hospital in which a surgeon operated on the wrong child, removing the tonsils and adenoids of a girl who was supposed to get eye surgery.

-- Anonymous, January 16, 2002

Answers

"In addition, the patient's incision site had not been marked with a pen, as recommended by error-prevention experts." I remember someone at TimeBomb describing how she had written instructions all over her body prior to some scheduled surgery. Things like, "if you are poking around here, you're at the wrong end!".

One of Dad's favorite stories is about a patient he encountered while interning back in the 1940s at a Brooklyn hospital. He decided the woman had appendicitis. The resident on duty thought he was nuts, cuz Dad was pointing to the wrong side. Dad had to fight to get a confirmatory x-ray since back then they were not routinely done. But there was a potential problem. He had to make sure the radiologist carefully marked the orientation of the x-ray, since as it turns out, all of her internal organs were reversed (I don't remember the name for that condition). Dad's diagnosis proved correct.

-- Anonymous, January 16, 2002


I'll remember to write some notes on myself if I ever go in for surgery. (:

-- Anonymous, January 16, 2002

Meemur,

I had to mark the ankle of the foot that I just had cut on. The mark is faint, but still there after nearly a month. Heck, I could just get the foot wet last Sunday. Now the marks that the Doctor made on me where he was going to cut are still there, as I cannot wash that place still.

It pays to let them know exactly what you think they are going to be working on, just to confirm it with them.

apoc

-- Anonymous, January 16, 2002


How about a tattoo, "Fragile, handle with care."

Or, "This end up."

[chuckle]

Writing directions on your body prior to surgery seems to be only good sense. But what if you're unconcious?

Maybe it would be logical to tattoo info like 'diabetic' or 'pennicilin allergy' etc. There would have to be an assigned place for those, but the wrist is good since most have bracelets already.

sure would be good for tattoo artists, huh?

-- Anonymous, January 16, 2002


Poor apoc! You're a road map!

Barefoot, I like your idea. I'd rather have med warnings tattooed on my body than guy's names. (:

-- Anonymous, January 16, 2002



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