Hospital says surgeon opened wrong side of patient's head

PROVIDENCE, R.I. -- 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 said.

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, Farrington said.

"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.