The Health Department has fined Rhode Island Hospital $150,000, after determining that a surgical team violated safety policies when it operated on the wrong finger of a patient on Oct. 22.

The surgical team failed to properly mark the fingers and failed to follow the rules for “time out,” a pause before surgery to verify the patient, procedure and site, the department’s investigation found. Indeed, the report said, Rhode Island Hospital was not even following the much-ballyhooed error-prevention protocol that was adopted statewide on July 1.

“This pattern of surgical errors is completely unacceptable and must be corrected to protect the safety of all patients at the hospital,” said Health Director David R. Gifford.

The October incident was the fifth wrong-site surgery at the hospital since January 2007.

In an order imposed Monday, the Health Department reprimanded the hospital, mandated observation of every surgery for a year, required full adoption of the statewide surgical protocol and required installation of video and audio monitoring in every operating room. Monday’s order also imposed the fine –– only the second time that the state has fined a hospital. The first time was in 2007 when the state fined Rhode Island Hospital $50,000 for the third wrong-site neurosurgery that year.

Rhode Island Hospital declined to make an administrator available for an interview on Monday. Instead, the president, Dr. Timothy J. Babineau, issued a statement saying that the hospital was asking for a meeting with state officials. He also reaffirmed its commitment to patient safety.

In the most recent incident, the surgeon performed two procedures on two parts of a patient’s middle finger. But he was supposed to perform one procedure on the middle finger and a different procedure on the pinky. After the error was noticed, he did the correct procedure on the pinky.

After the incident, hospital officials blamed an ambiguity in the protocols. The team had regarded the surgery as a single procedure on one hand rather than two procedures on two fingers. So only the hand was marked, and no time-out was held before the second operation.

But the Health Department found no ambiguity. According to its report, the rules specify that the fingers should be marked and two time-outs held.

After the patient’s family was informed of the error and consented to surgery on the pinky, the team returned to the operating room and went to work –– again without performing a time out, a violation of protocol that Gifford called “disturbing.”

Gifford said that clinical staff members at Rhode Island Hospital don’t seem to fully appreciate the purpose of the time out, “still viewing it as some sort of administrative function.” The hospital, he said, has been “approaching the problem from a bureaucratic standpoint” with new policies and forms, rather than addressing an underlying problem with the institution’s culture.

“Changing institutional culture and beliefs takes some time,” Gifford said. “But this has been going on for a couple of years there.”

The surgeon and a surgical fellow have been referred to the state Board of Medical Licensure and Discipline for investigation. The roles of two or three nurses are under review for possible referral to the state Board of Nursing.

Gifford noted that the surgeons involved in errors have been described as highly regarded. “When you have multiple people reporting on how excellent the nurses and physicians are involved in these cases, it starts to raise a question,” he said. “If this is happening among the, quote, best surgeons, then it’s more troubling.”

The statement from hospital president Babineau noted that the hospital is working with the Joint Commission, a national accrediting agency, on “an innovative project to reduce wrong-site events.” The Joint Commission last week provided “a set of recommendations” that the hospital had asked the Health Department to adopt in its compliance order. Instead, said hospital spokeswoman Jane Bruno, the Health Department has taken “a totally different approach.”

On Oct. 26, a few days after the wrong-site finger surgery, the Health Department ordered that, for every surgery at Rhode Island Hospital, a licensed clinical professional who is not part of the surgical team must observe the surgery with an eye to site marking and time out procedures. Monday’s order requires this monitoring to continue until the hospital hires a consultant, within 30 days, to continue this direct observation for at least a year, and report to the Health Department quarterly.

The hospital is also required to:

•Adopt the statewide protocol for safety checklists, surgical marking, and developing a plan to revise protocols and update staff.

•Shut down surgery for one day and conduct a mandatory training and review of surgical procedures.

•Install audio and video monitoring equipment in every operating room and, with patient consent, review two surgical events each year for each surgeon.

•Prepare a summary of every surgical error from 2005 to the present, and send it to four government and accrediting agencies.

ffreyer@projo.com