PROVIDENCE -- The state medical board has found that a well-respected Rhode Island obstetrician-gynecologist performed the wrong surgery on a patient who shared the same last name with another patient.

Dr. Marguerite Vigliani, who has hospital privileges at Women & Infants Hospital, Rhode Island Hospital and Roger Williams Medical Center, reported the error after the March 2005 surgery. Other than the public acknowledgement of her error, she faces no financial penalties, probation or punishment, the state Board of Medical Licensure and Discipline said.

"This truly was an error in judgment made by a physician who's otherwise a very good physician with a long medical practice characterized by good medical practice," said Robert S. Crausman, chief administrative officer for the state medical board.

At Women & Infants Hospital, she removed the ovaries of a 53-year-old woman who was expecting to have only a vaginal hysterectomy, the board said in its report.

When Vigliani learned after the surgery that the patient had not expected to have her ovaries removed, the doctor reported the incident to the hospital administration and together the doctor and hospital reported it to the state medical board, said Crausman.

"Clearly, a patient has the right to expect when they go in for a particular surgery that that's the surgery that's going to be done, and there was clearly an error in judgment in the Dr. Vigliani case," Crausman said. "At the same time, if there's going to be a safer health care environment tomorrow than we have today we have to encourage self-reporting of errors and mistakes, which is exactly what she did."

Board records say that Vigliani met with the patient six weeks before the surgery because of problems relating to uterine prolapse.

The woman returned to the office later to schedule a vaginal hysterectomy. That same day, a second patient with the same last name met with Vigliani and discussed having her ovaries removed because of her family history of ovarian cancer.

On the day of the surgery for the first patient, Vigliani and the operating team conducted what is called a "time out" exercise, when they run down a checklist to make sure they are about to undergo the proper procedure.

During the "time out," the circulating nurse called attention to the discrepancy between the planned surgery and the consent form the patient had signed describing her operation. She brought it to the attention of the charge nurse.

But Vigliani was certain she had discussed both procedures with the patient before the surgery, Crausman said. Two other medical personnel who participated in that conversation could not confirm or deny for the state medical board whether both procedures were discussed before the surgery, Crausman said.

Ultimately, the charge nurse, who has a supervisory role over the operating rooms, allowed both surgeries to proceed, Crausman said.

"They could not have proceeded without the charge nurse proceeding," Crausman said. "Dr. Vigliani presented her logic and clear memory and was then allowed to proceed with the surgery."

After the operation, Vigliani was "surprised" to learn the patient had not wanted her ovaries removed, said Crausman, and "very appropriately reported it to all the authorities."

Crausman said Vigliani "has worked earnestly" to ensure that such errors are less likely in the future.

"The order entered [by the state medical board] was that she will use her knowledge and skill to assist others in remediating the problem of medical errors," said Bruce McIntyre, legal counsel for the state medical board.

Vigliani did not return a telephone call placed to her office.

The medical board disciplined two other physicians.

Dr. Daniel Collins, a family medicine and urgent care doctor in Coventry, is on probation for three years for not properly inventorying his medicine twice a year, keeping improper paperwork when destroying drugs and not maintaining accurate records of the controlled substances at his practice, the medical board said.

Collins administered medications at his practice, Pawtuxet Valley Urgent Care, at 982 Tiogue Ave. in Coventry. He must now alter how he does business and must pay an administrative fee of $500. In addition, the Drug Enforcement Agency levied a $10,000 penalty against Collins, Crausman said.

"Our investigation did not lead us to believe that there was any diversion of narcotics going on, but rather these were just errors in meeting the standards," Crausman said.

Dr. Samir F. Jain, who is in post-graduate training and therefore only has a limited medical license, is on probation for the rest of his post-graduate training and must contract with the Physician's Health Committee. The committee, sponsored by Rhode Island Medical Society, works with physicians who have had health problems including medical illness, psychiatric illness and substance-abuse problems, Crausman said.

Crausman said he could not comment on Jain's reason for contracting with the Physician's Health Committee.

kbramson@projo.com / (401) 277-7470

tmooney@projo.com / (401) 277-7359