A doctor at the Miriam Hospital yesterday operated on the wrong knee of a patient undergoing elective surgery, despite the hospital’s increased focus on preventing such wrong-site surgeries.

The surgical team had apparently followed the key safety protocols, including marking the correct knee and pausing to verify the site before operating –– but somehow still made the error, according to Dr. Kathleen C. Hittner, hospital president and chief executive officer.

The mistake was first noticed by the patient when she regained consciousness. The hospital then performed the surgery on the correct knee, and the patient is doing well, Hittner said. The patient was scheduled to go home yesterday.

Miriam Hospital is part of the Lifespan hospital group, which includes Rhode Island Hospital, where three wrong-site surgeries occurred last year. Eight wrong-site surgeries have occurred around the state in the past decade, prompting the Health Department to consider statewide regulations addressing the issue.

Hittner said Miriam had recently instituted policies intended to prevent these very types of errors.

According to Hittner’s account, which she said was based on interviews with participants conducted right after the incident, the surgeon marked the correct knee with the word “yes.” Even so, the wrong knee was mistakenly draped for surgery. Then, in the operating room, the team took a “time out” before surgery to verify that they were about to do the correct surgery on the correct site.

“That was done by six people,” Hittner said. “They all agreed that they had the proper side ready. … They knew the surgery was supposed to be on the left side. Somehow the system didn’t work the way it should. Somehow they did not recognize it.”

The surgery took place at 7:30 a.m., the first case of the day, Hittner said. It was an outpatient arthroscopic procedure, in which a scope and surgical instruments are inserted through tiny incisions. The patient was being treated for arthritis and an injury. The hospital declined to name the surgeon or the patient.

Hittner said that, upon awakening in the recovery room, the patient was mostly upset to discover that her sore, left knee had not been fixed. When the hospital agreed to repeat the surgery on the correct knee, the patient was pleased, according to Hittner. “She’s been a real trouper,” she said. Although only one knee was hurting, both knees had arthritis, so the surgeon could not tell he was working in the wrong place, Hittner said.

Hittner said she felt “tremendous sadness, sorrow” over the incident. “I can’t believe it actually happened to us, because we worked so hard to prevent it,” she said. “We’re really sorry that this happened. We’re going to work hard to make sure it never happens again.” She said the staff, all highly experienced, was “devastated.”

The hospital reported the incident to the Health Department, which sent a team to begin investigating yesterday, according to Helen Drew, a Health Department spokeswoman. Drew said the department is developing statewide regulations to prevent wrong-site surgeries at every hospital. But if recent experience is any indication, this may prove daunting.

At Rhode Island Hospital, the third wrong-site surgery last year came just four months after the second one and in spite of a concerted effort to prevent the mistakes. Last year’s cases at Rhode Island Hospital involved three patients who had bleeding on the brain. In each case, a neurosurgeon, seeking to drain the blood, drilled into the side of the head that didn’t have the excess blood.

Around the country, wrong-site surgery “continues at an alarming rate” despite efforts to prevent it, said Dr. Peter D. Angood, vice president and chief patient safety officer with the Joint Commission, an agency that accredits hospitals. In 2004, the Joint Commission required all hospitals to verify the patient, procedure and surgical site before beginning surgery, to mark the surgical site, and to take a time-out before surgery to make sure that the team is about to do the right thing.

Those rules haven’t made a dent. The Joint Commission continues to receive 8 to 10 reports of wrong-site surgeries per month, and sometimes as many as 18. Starting Jan. 1, the commission will add more detailed, prescriptive requirements on how to carry out those three basic steps. For example, the new requirements will specify what type of professionals should be involved in each safety check, how surgical sites should be marked, and what should occur during a time-out.

Asked whether an event such as yesterday’s surgical error at Miriam could signal deeper problems in an organization, Angood said, “It’s a flag that requires the situation to be evaluated and analyzed critically in order to assess whether there are deeper problems.”

“This is an essential question not only in American health but global health,” Angood added. “Why do bad things continue to happen, in organizations that provide high levels of care? … Even in the best of institutions, bad things are still occurring.”

As is often the case with wrong-site surgeries, yesterday’s patient at Miriam is not expected to suffer long-term harm from the incident. But it’s still a serious matter, Angood said. “Perhaps it’s not physically damaging for some patients. But it is psychologically damaging for all patients. It gets to the core of trust and honesty within the system. It also creates morale issues within the same system: ‘How come we can’t get this done?’ ”

ffreyer@projo.com