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RI Hospital Hit with More Regulatory Action by Department of Health

— June 18, 2018

RI Hospital Hit with More Regulatory Action by Department of Health

Rhode Island Hospital has received a multitude of scrutiny over the past decade.  It has been hit by state regulators with citations regarding surgeries being executed on the wrong sides of patients’ bodies and on the wrong patients altogether.  It has been in and out of court with families taking legal action, entrenched in lawsuits.

Just in the past three years, juries hit the hospital with nearly $90 million in judgments in two cases.  This month, an agreement was reached between the hospital and the Rhode Island Department of Health (DOH), which set forth a series of regulatory actions including a required $1 million to be allocated to new training requirements.

“Whenever preventable errors occur in hospital settings, it is essential that we scrutinize those errors carefully and that facilities make the systems changes needed to ensure that they do not occur again.  Rhode Island is home to some of the preeminent healthcare facilities in the region and the country.  Inspections and regulatory work by the Department of Health are critical to ensuring that our hospitals maintain that status, and to ensure that the healthcare system as a whole continues to provide quality patient care,” said Director of Health Nicole Alexander-Scott, MD, MPH.

Photo by Ken Treloar on Unsplash

The most recent action taken by the DOH against RI Hospital indicated it had “failed to implement and sustain processes and systems to provide care and services in accordance with its written policies and procedures pertaining to patient identification and verification, verification of procedure site/side, and provider’s orders for diagnostic services in the following cases:

  1. On 2/21/2018, Patient ID #2 underwent a computed tomography angiography of the brain and neck intended for another patient.
  2. On 2/26/2018, Patient ID #1 was not c01Tectly identified and as a result, underwent an angiogram intended for another patient.
  3. On 3/12/2018, Patient ID #3 unde1went a surgical ve1tebroplasty on Patient ID #3’s C-6 which was intended to be done on C-7.
  4. On 3/16/2018, Patient ID #8 underwent a mammogram of the right breast intended for another patient.”

These are very serious allegations, and yet, they are not uncommon. “Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S. Their figure, published May 3 in The BMJ, surpasses the U.S. Centers for Disease Control and Prevention’s (CDC’s) third leading cause of death — respiratory disease, which kills close to 150,000 people per year,” according to Johns Hopkins Medicine.

In October of 2010, it was reported that that Rhode Island Hospital was hit with a $300,000 fine by the DOH when, during neurosurgery, a small piece of a drill bit broke off and was left lodged in a patient’s scalp.  The Department of Health conducted a joint investigation with the Center for Medicare & Medicaid Services (CMS) and discovered that the hospital was not ensuring that the operating room staff follows 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 facility.  The required action steps were not taken.

“We found evidence they were not following their policies once again,” said Dr. David Gifford, Director of the DOH, “and the staff was reporting issues in the operating room that weren’t addressed.”

The hospital was also fined $150,000 in 2009 and was ordered to put video cameras in all its operating suites and must undergo surgery procedure protocol observation for at least one year in response to another wrong-site surgery that took place at the hospital.

“The hospital’s continued failure to effectively implement policies and practices to ameliorate this particular problem is frustrating and significantly damages the public’s perception of safety and the credibility of R.I. Hospital’s ability to consistently provide for safe surgical procedures,” wrote Gifford.

These incidents are in addition to the payouts awarded in lawsuits against the facility and its staff over the years.  The DOH will continue to keep close tabs on the hospital in an attempt to ensure compliance and take action as needed.


A Decade of Surgery Problems Plague Rhode Island Hospital

Third wrong-sided brain surgery at R.I. hospital

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