A Rhode Island hospital recently made the news due to a higher than expected frequency of wrong-site surgery. Rhode Island Hospital, located in Providence, will pay $150,000 and install video cameras in all of its operating rooms after performing its fifth wrong-site surgery since 2007, according to the state’s Department of Health. You can find additional stories here and here. Now the hospital’s home page has a video of the president talking about safety.

Rhode Island Hospital- have you been here?

I could ask “why did it take so long to discover this?” Or better, “why is the hospital still in business?” Or “what about the doctors?” The sad reality is that many hospitals neither report such occurrences, as required by state and federal regulations. Many do not report the physicians or nurses involved as required by many state agencies. Many simply attribute it to some “system” error.

A colleague related an experience at a tertiary care children’s hospital. In a particularly egregious occurrence the surgeon made the wrong incision for the planned procedure. He hadn’t reviewed the chart before the operation. He had refused to participate in the required “time out” designed to prevent such occurrences. His response afterwards, “no harm, no foul.” He was not disciplined by either the state medical board or the hospital. At another institution a gastroenterologist performed a procedure on the wrong patient- he was subsequently made the division chief. The entire discipline from the state medical board- 10 hours of additional education in medical record keeping.

Such occurrences are wholly preventable. That’s why insurers and the government refer to them as “never” events. Patients should not pay for these occurrences. In fact normal liability limits should not be applicable since these occurrences in most cases result from extreme negligence or recklessness not simple medical negligence.

The bottom line- ask your doctor if (s)he has ever had such an occurrence. Check your state medical board for your physician’s record of disciplinary actions. Ask the medical staff office at your local hospital how many such occurrences there have been.

It’s your life. It’s your health. Take care and take charge.