A doctor at Rhode Island Hospital started to operate on the wrong side of a patient’s head Friday, barely four months after a wrong-site surgery at the same hospital.

The Health Department yesterday reprimanded the hospital and fined it $50,000, noting that Friday’s incident was the third wrong-site surgery at the hospital this year, and the fourth in six years — all involving neurosurgery. Health Director David R. Gifford said that as far as he knows, this is the first time the department has fined a hospital.

Friday’s incident occurred at a patient’s bedside in the neurosurgical intensive-care unit, according to the hospital. The patient, an 82-year-old woman, had bleeding between her brain and skull. The chief neurosurgery resident started to cut into the patient’s head to remove the blood, but on the wrong side. The resident broke the skin but did not reach the skull.

At that point the resident — a doctor in the seventh year of specialty training — realized the error and stopped the procedure. “The patient received one stitch to close the wound, and the procedure was then performed on the correct side, with good results,” the hospital statement said. The patient was listed in fair condition yesterday.

Rhode Island Hospital notified the Health Department of the error on Friday, and Health Department inspectors made an unannounced visit on Sunday. They determined that no staff member who was present during the procedure had verified the surgical site as required by hospital policy.

Gifford ruled that the hospital was not meeting the requirements of its license because of its “continued failure to provide adequate care to patients having neurosurgery.”

He ordered it to have a fully licensed physician attend every neurosurgical procedure anywhere in the hospital, and to require the operating physician to complete a checklist before starting, with both the doctor and a nurse or technician verifying the correct patient, procedure and surgery site. The hospital must provide the checklist form to the Health Department by tomorrow. Gifford also required a plan for educating doctors about the protocols to prevent wrong-site surgery.

“We have talented, dedicated professionals working hard to provide the best care to our patients, but we clearly need to do more,” a hospital statement said. “Our policies and procedures cannot be effective unless every person understands them and follows them to the letter.”

Both Rhode Island Hospital and the Health Department declined to name the surgeon who performed Friday’s procedure. The hospital said that “corrective action” had been taken with the staff involved but would not elaborate. The Health Department said that the licensing boards for doctors and nurses would investigate whether to take disciplinary action against any of the professionals.

But Gifford noted that, given the repeated problems involving different people, the blame probably lies with the hospital’s systems for preventing errors rather than any individual.

“Too much emphasis has been on individuals and education, and not looking at the system,” Gifford said. Gifford said the hospital needs to have simple procedures that make it hard to make errors. For example, the hospital had a “time-out” procedure in which the staff pauses before surgery to make sure everything is in order. But the plan wasn’t specific enough and did not require staff to check the primary information sources, such as x-rays.

Gifford said that the surgery occurred at midday and that the doctor’s work hours were not a factor in the error.

The department’s statement of deficiencies noted that “the nurse was a travel nurse and not familiar with the procedure.” Travel nurses are hired through agencies to fill in when a hospital does not have enough of its own nurses available. Gifford said that every hospital uses travel nurses — and must have procedures in place to make sure any newcomer knows the protocols.

THE MOST RECENT previous incident at Rhode Island Hospital, which occurred July 30, involved an emergency procedure in an operating room. An 86-year-old man arrived at the hospital emergency room three days after a fall, and was found to have blood between his brain and skull. Neurosurgeon J. Frederick Harrington didn’t check the CT scans to verify which side to work on, and instead relied on his memory. Harrington drilled into the wrong side of the patient’s head, realized his error, and immediately operated on the correct side. The patient died a few days later, but preliminary information from the state medical examiner did not find a connection between the surgical error and the patient’s death, Gifford said. The medical examiner has not yet determined the cause of death.

Harrington was barred from practicing surgery for 10 weeks, and Rhode Island Hospital also suspended his privileges to work there. Harrington’s license has since been restored without restrictions, but he has not regained his privileges at Rhode Island Hospital.

In response to this incident, the Health Department on Aug. 2 ordered the hospital to hire a quality consultant and to make sure that two fully licensed physicians confirm the site before every surgery. “We have not seen an adequate response in the hospital’s system and protocols since the last compliance order was issued,” Gifford said. “While the hospital has made improvements in the operating room, they have not extended these changes to the rest of the hospital.”

In addition to the quality consultant, who visited two weeks ago, the hospital hired three other independent consultants to examine policies and procedures in neurosurgery. Yesterday the Health Department demanded to see their reports by Dec. 15.

Asked how such an error could occur yet again, hospital spokeswoman Jane Bruno said that much of the effort over the past four months has focused on the problems underlying the July 30 incident, which involved communication between the emergency and operating rooms. New procedures have been put in place to deal with that, but had not yet been extended to bedside procedures.

Rhode Island Hospital has 15 days to file a plan of corrections with the Health Department in Friday’s incident.

Yesterday’s order from the Health Department can be found at www.health.ri.gov/hsr/facilities/hospitals/index.php

ffreyer@projo.com