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Anesthesia error results in a surgical near miss

01:00 AM EDT on Tuesday, June 30, 2009

By Felice J. Freyer

Journal Medical Writer

A surgeon anesthetized the incorrect eye of a patient about to undergo eye surgery at the Miriam Hospital this month, but the error was discovered before the patient entered the operating room. The surgery was then rescheduled.

The hospital reported the incident to the Health Department, which is still investigating, department spokeswoman Annemarie Beardsworth said Monday.

Miriam Hospital spokeswoman Linda Shelton said the incident occurred on June 11. She said the surgical site was correctly marked and a time-out was taken before the anesthesia was administered.

But Shelton did not pinpoint what went wrong. When asked what the hospital would do differently in the future, she said, “There are some changes that are being looked at to ensure that there are redundancies in every single step of the process.”

Shelton characterized the incident as a near-miss rather than a medical error. The hospital’s safety process “was instrumental in identifying the error before the patient went into the operating room,” she said.

She asserted that Rhode Island’s incident-reporting requirements are more stringent than in other states, where, she said, such events happen in greater numbers without anyone knowing about them. Miriam Hospital, Shelton said, continues to work to make surgery “as safe as possible.”

The hospital placed the surgeon on administrative leave while it investigated, and the surgeon has since been reinstated, Shelton said. She declined to say whether the hospital disciplined anyone for the wrong-site anesthesia.

Health officials have not taken any disciplinary action against Miriam or any professionals there, but the state’s investigation is not complete.

News of the incident comes at a time of heightened awareness of surgical errors in Rhode Island, where five wrong-site surgeries have been reported since 2007. One of them was last year at the Miriam, where a doctor performed arthroscopic surgery on the wrong knee.

The most recent wrong-site surgery occurred May 11, when a surgeon started to operate on the wrong side of a child’s mouth during a procedure to correct a cleft palate at Hasbro Children’s Hospital.

ffreyer@projo.com

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