A surgeon on Monday began operating on the wrong part of a child’s mouth during surgery to correct a cleft palate at Hasbro Children’s Hospital, the fifth wrong-site surgery in Rhode Island since 2007.

The error was noticed during surgery and the correct procedure then performed, “with good results,” Dr. Timothy J. Babineau, president of Rhode Island Hospital, of which Hasbro is part., said in a statement. “The patient is in good condition and we do not anticipate any further complications related to this error,” he said.

The hospital apologized to the patient and the family. It also placed the surgeon and the surgical team on administrative leave after a preliminary investigation found that “at least one of our standard policies was not followed,” Babineau said.

The state Health Department, notified of the error late Monday, sent a half-dozen inspectors from its facilities regulation division and the medical and nursing licensing boards to Rhode Island Hospital on Tuesday and Wednesday. They have been interviewing staff and looking over the operating room to pinpoint the cause of the error and to advise the health director on whether to take disciplinary action.

Health Director David R. Gifford said he doesn’t expect a simple answer: “As in all of these cases, it’s never one individual, nor is it ever one isolated event.”

Gifford said that Monday’s oral surgery involved one side of the roof of the child’s mouth, and the team initially started working on the wrong side. He said the patient was a “young child” between the ages of 5 and 15.

“This is an event that should absolutely never happen. There just is absolutely no excuse for it happening,” said Dr. Mark R. Chassin, president of the Joint Commission, the national organization that accredits hospitals and other health-care institutions. Hospitals around the country reported 116 wrong-site surgeries last year, making it the most common of the “sentinel events” –– severe, dangerous errors –– that are tracked by the Joint Commission.

“The vast majority these events are not the fault of people, they are the fault of processes that don’t work,” Chassin said in an interview Wednesday. “The state of our art and science in health care, unfortunately, is that we don’t know how to perfect these processes yet to guarantee that it never happens.”

Hospitals are supposed to have systems in place, such as checklists, “time outs” before surgery and multiple layers of verification, to catch human errors before they are carried out.

The problem, Chassin said, is that the safeguards have become an added layer of administrative chores that time-pressed health professionals are apt to perform by rote. Now, patient-safety experts are looking at ways to integrate safety protocols into the flow of clinical care. In fact, the Joint Commission plans to work with hospitals in Rhode Island to develop and test some of these new processes, Chassin said.

In three instances in 2007 at Rhode Island Hospital, doctors intending to drain blood that had pooled inside a patient’s skull drilled into the wrong side of the head. The Health Department fined the hospital $50,000 and suspended a surgeon. The hospital replaced its chief of neurosurgery and hired outside experts to review its safety procedures.

In 2008, Miriam Hospital, which is also part of the Lifespan hospital group, operated on the wrong knee of a patient undergoing arthroscopic surgery. The Health Department reprimanded the hospital, the surgeon and two nurses. Both Miriam and Rhode Island are part of the Lifespan hospital group.

Asked why these problems keep recurring, despite efforts to prevent them, Gifford said, “We are asking ourselves that a number of times over here. Both hospitals have made some progress but clearly not enough.”

But Gifford said that safety measures that seem simple –– left or right? –– can be complicated to carry out. For example, the surgical team is supposed to mark the spot where surgery should take place. But, he said, “How do you mark inside the mouth? The standard policy is silent on stuff in the mouth. It doesn’t need to be marked.”

He also speculated that there may be a culture of “it couldn’t happen to me” that is hard to break down.

Gifford noted that wrong-site surgeries probably occur with equal frequency in other states but may not get the same level of attention. “Both the hospitals and the Health Department are making it a priority to publicize them because that’s how we’re going to change the culture,” Gifford said.

Meanwhile, hospitals around the state have teamed up to standardize the marking of surgical sites, so that the many surgeons who practice at more than one hospital will have consistent rules.

Additionally, under a new state law intended to reduce medical errors, the state’s first “patient safety organization” has been certified. The group, a private company from Pennsylvania, will analyze data from hospitals to identify ways to improve safety.

“The hospitals that are working on this problem are serious about getting rid of it,” said Chassin, of the Joint Commission. “This is not a problem of lack of will, lack of interest or lack of attention. We don’t have the tools yet to be able to guarantee that events like this, which should never happen, literally don’t ever happen.”

ffreyer@projo.com