The Health Department yesterday ordered Rhode Island Hospital to hire a consultant and double-check surgical sites after a neurosurgeon operated on the wrong side of a patient’s head on Monday — the second wrong-site procedure this year at the hospital, and the third in six years.

Additionally, the surgeon who performed Monday’s operation, Dr. J. Frederick Harrington, has been suspended from the hospital and ordered by the Health Department to stop doing surgery and undergo an evaluation. Harrington was not involved in the two earlier incidents.

The patient in Monday’s surgery is an 86-year-old man who, according to Rhode Island Hospital, came to the emergency department with increasing lethargy after a fall three days earlier. When it was discovered that he had blood between his brain and skull on the left side, he was taken to the operating room for emergency surgery.

Harrington and others “failed to make an accurate assessment of the correct location,” Health Department documents said, and operated on the wrong side. When the error was discovered, Harrington immediately performed the surgery on the left side. Rhode Island Hospital reported that the patient’s vital signs were stable yesterday, but its e-mail to employees noted that he had not regained consciousness.

Health Director David R. Gifford said the order against the hospital — called an “immediate compliance order” — is the first such order that his staff can recall ever issuing against a hospital. It indicates that the problem was serious enough to require immediate action even before a full investigation can be completed.

Gifford said he issued the order because of the “pattern” of wrong-site surgeries, all involving neurosurgery at Rhode Island Hospital. In addition to Monday’s surgery, wrong-site neurosurgery procedures were performed in January 2007 and in December 2001. In both cases the hospital pledged to conduct training and improve procedures.

“They may have policies written, but are people following them?” Gifford said. “The hospital needs to change its culture and its systems. … Maybe these were three isolated events. It certainly doesn’t look that way.”

The Health Department learned of the error on Tuesday, because state law requires hospitals to report such incidents within 24 hours. The department plans to continue investigating what went wrong and monitoring the hospital’s response, Gifford said.

“We deeply regret the incident that occurred on Monday, July 30,” the hospital said in a statement yesterday. “This should not have happened: We have policies and procedures in place to prevent an incident like this from occurring. The preliminary investigation indicates that at least one of our standard policies was not followed.”

THE TWO OTHER wrong-site surgeries at Rhode Island Hospital also involved bleeding on the brain.

In December 2001, neurosurgery residents drilled holes in the wrong side of a patient’s head after a CT scan was placed backward on the viewing screen. When they realized their mistake, they operated on the other side, and the patient recovered. A Health Department investigation found that the hospital had failed to follow its own policies requiring multiple checks of surgical sites.

Dr. John Duncan III, Rhode Island Hospital’s neurosurgeon-in-chief, supervised the 2001 surgery. In 2003 the Health Department found Duncan responsible for the error and ordered him to study and make recommendations on preventing medical errors.

The next incident occurred in January. Working at the bedside, a neurosurgery resident and a nurse placed a drain in the head of a 91-year-old patient to remove the blood. But they put it on the wrong side.

A Health Department investigation found that they failed to take a “time out” to verify and document the patient’s identification and surgical site, in violation of hospital policy. The resident said he knew about the policy but had never seen the form and had never seen anyone use the form. The nurse and her manager did not know about the policy.

In its “plan of corrections,” the hospital promised to better educate the staff.

But Monday’s incident also involved a failure to pause and double-check before going into surgery, according to Bruce W. McIntyre, lawyer for the state Board of Medical Licensure and Discipline, which conducted a preliminary investigation of Harrington’s actions.

“The patient was brought from the emergency room right into the operating room without the nursing check,” McIntyre said. Communication among the emergency-room, radiology, and the nurses was inadequate. The CT scan “was looked at once, and then Dr. Harrington went from memory,” McIntyre said. “There were staff failures and there was doctor failure.”

The consent form that relatives signed did not specify which side the surgery would be performed on, because the nurse who prepared it didn’t know, McIntyre said.

HARRINGTON was also involved in a similar wrong-site error at another hospital earlier this year, according to McIntyre. In that incident, Harrington was called to the hospital in the early-morning hours to treat another case of blood on the brain.

Harrington was not sanctioned for that mistake because so much of the blame belonged with the hospital (not Rhode Island Hospital in this case), which had “a host of system problems,” McIntyre said.

The evaluation that the medical board is requiring of Harrington, 50, will focus on his health, McIntyre said, to make sure there isn’t an organic cause for his errors. It is not a competency evaluation. “We know he’s a competent surgeon,” he said. “His surgical competence is not in question at all.”

Harrington could not be reached yesterday. His lawyer, Robert Goldberg, declined to comment because the investigation is not complete.

Wrong-site surgery is probably the most common of the serious, preventable medical errors that occur at hospitals. Since 1996, some 550 incidents have been reported to the Joint Commission, the national accrediting agency.

A busy, urban hospital such as Rhode Island has more opportunities to make mistakes, but that’s why it needs to be “exquisitely more vigilant,” McIntyre said.

“Very often, having practices and procedures in place isn’t enough,” he said. “You have to have total buy-in from the staff.”

Hospital spokeswoman Jane Bruno said the hospital is in the process of hiring the consultant as required by the Health Department; in addition, it plans to hire “a prominent neurosurgeon to review our entire neurosurgical program.”

The Health Department also ordered that two physicians identify each surgical site. Bruno said that was already hospital policy but declined to discuss whether it had been followed on Monday.

“The public trusts and relies on our hospital for this care,” the hospital’s statement concluded. “We can and must do better to ensure the safety of our patients.”

Health Director Gifford urged people anticipating surgery to review surgery plans and consent forms with surgeons ahead of time, and to follow the tips for patients at the Joint Commission’s Web site: www.jointcommission.org/PatientSafety/UniversalProtocol/wss.tips.htm

ffreyer@projo.com