An orthopedic surgeon at Rhode Island Hospital operated on the wrong finger during outpatient hand surgery on Thursday, the fifth in a string of wrong-site surgeries at the hospital over the past 2½ years.

The mistake occurred despite multiple efforts to eliminate such errors, including statewide adoption of surgical safety procedures and a recent collaboration between Rhode Island Hospital and the Joint Commission, an accrediting agency.

“Frustrated –– in capital letters –– is probably the way to describe the mood here at the department,” said state Health Director David R. Gifford. In 2007, the department reprimanded Rhode Island Hospital and fined it $50,000 for the third wrong-site error that year, each involving a different doctor drilling into the wrong side of a patient’s head to drain blood.

Asked whether he thought there was something fundamentally awry at Rhode Island Hospital, Gifford said, “I am wondering that myself.” But he emphasized that he still had not heard all the facts. Health Department investigators were at the hospital all day Friday.

Mary Reich Cooper, senior vice president and chief quality officer at the hospital’s parent company, Lifespan, said that Thursday’s incident did not reflect a pattern at Rhode Island Hospital, the state’s largest hospital and Brown University’s main teaching hospital. Rather, she said, it demonstrates the difficulty and complexity of preventing such errors despite what she described as the hospital’s deep commitment to safety.

The team involved in Thursday’s surgery followed the protocols –– correctly verifying the patient, procedure and site –– but misinterpreted one aspect of the rules, Cooper said. The team regarded the surgery as a single operation on a hand, rather than two separate procedures on two fingers. So the verification protocols were followed only once, and only the hand was marked rather than the individual fingers. In the future, Cooper said, surgical teams will mark each finger and verify the finger before each procedure.

Cooper gave this account of the incident. After the team had verified that they were performing the right procedure on the correct hand of the right patient, the surgeon operated –– correctly –– on one finger. Without re-verifying, he then performed the second surgery on a different joint of the same finger. But he was supposed to operate on a different finger. The patient’s illness affected the entire hand so it was not obvious that the doctor was working on the wrong joint, Cooper said.

The error was noticed before the patient left the operating room. The patient’s relative, informed of the error, gave permission to perform the surgery on the correct finger. That surgery was done without incident and the patient went home that day.

The team immediately reported the incident to the hospital administration. The surgeon canceled his remaining surgeries for the day and the surgical team spent the day on administrative leave, analyzing what went wrong. Most were back at work Friday.

Cooper described the surgeon as “a great surgeon with a great reputation” who was deeply focused on performing the procedure correctly. The leadership at Rhode Island Hospital, she said, is committed to safety. “Every time one of these kinds of things happen, that commitment is just made stronger,” she said.

The previous wrong-site surgery at Rhode Island Hospital occurred in May, when a surgeon operated on the wrong side of a child’s mouth during a procedure to correct a cleft palate. The hospital did not have any protocol for verifying surgical sites in places that, like the inside of the mouth, cannot be marked. The surgeon did mark the outside of the child’s face, but he marked the wrong side and failed to verify it with the surgical team.

“These are events that should never happen,” said Dr. Mark R. Chassin, president of the Joint Commission, a private agency that inspects and accredits health-care organizations. “The unfortunate truth is that no hospital today in the U.S. or around the world ... can guarantee that they will never happen. We do not know how to perfect our processes to ensure these [errors] never happen.”

The Joint Commission estimates that 40 wrong-site surgeries occur every week around the country. Its 15 years of efforts to stop wrong-site surgeries have failed to lower the incidence nationwide.

Trying a new tack in error prevention, the Joint Commission has started working directly with hospitals to address patient safety. Its new Center for Transforming Healthcare is working with Rhode Island Hospital and Newport Hospital in a pilot project on how to prevent wrong-site surgeries. The work started over the summer, searching through procedures for the glitches and pitfalls than can lead to errors.

“We’re still in the assessment stage,” Chassin said. “It’s going to take a while to understand all of the complexities of the processes that lead to the risk of this kind of problem happening. Especially at a hospital as large and complicated as Rhode Island Hospital, there are a lot of these processes and many variations of those processes.”

Asked whether Thursday’s incident indicated something deeply wrong at Rhode Island Hospital, Chassin said no. “Why there is a particular cluster over almost 10 years at this hospital I can’t explain at the moment. We haven’t been in there long enough to know. We certainly have not seen the kind of denial or serious avoidance of the potential for real problems that we do see in some places.”

Chassin advises patients everywhere to question their surgeons in advance about the exact steps that will be taken to prevent an error.

Although frightening, wrong-site surgeries are less common and less harmful than other hospital mistakes, such as giving the wrong medication or spreading an infection.

“In the large majority of cases of this kind of error, the harm is either minimal or it’s transient,” Chassin said. “As shocking and difficult to understand as this problem is, it mostly does not leave patients with lasting harm.”

ffreyer@projo.com

Chronology of wrong-site errors

1998: A Kent Hospital surgeon performs arthroscopic surgery on the wrong knee.

Dec. 21, 2000: A surgeon operates on the wrong child, removing tonsils and adenoids from a girl scheduled for eye surgery, at Hasbro Children's Hospital, which is part of Rhode Island Hospital.

Dec. 12, 2001: A Rhode Island Hospital neurosurgery resident drills holes in the wrong side of a patient's head, in a procedure to relieve bleeding on the brain. The CT scan was placed backward on the viewing box.

2004: A Miriam Hospital anesthesiologist inserts a catheter on the wrong side of the neck of a patient about to undergo a procedure to bypass a blocked artery.

March 2005: A Women & Infants Hospital obstetrician removes the ovaries of a woman who was supposed to have only her uterus removed, confusing the woman with another patient who had the same last name.

September 2006: A neurosurgeon at Roger Williams Medical Center drills into the wrong side of patient's head in an emergency procedure to drain blood after an injury.

January 2007: A Rhode Island Hospital neurosurgery resident and a nurse place a drain on the wrong side of a patient's head to remove blood.

July 30, 2007: A neurosurgeon at Rhode Island Hospital cuts open the wrong side of a patient's head, also to drain blood.

Nov. 23, 2007: A Rhode Island Hospital neurosurgery resident starts to operate on the wrong side of a patient's head in a bedside procedure to drain blood on the brain. Health Department reprimands the hospital and fines it $50,000.

September 19, 2008: A Miriam Hospital doctor operates on the wrong knee of a patient undergoing arthroscopic surgery.

February 2009: The state Health Department reprimands a doctor and two nurses for their roles in the Miriam knee operation.

May 11, 2009: A Rhode Island Hospital surgeon operates on the wrong side of child&rsquos mouth during surgery to correct a cleft palate.

June 2009: A Kent hospital doctor inserts an intravenous line into the wrong arm of a patient and later injects dye into the wrong hip of another patient.

June 11, 2009: A Miriam Hospital surgeon anesthetizes the wrong eye of patient about to undergo eye surgery, but the error is discovered before the patient enters the operating room.

June 30, 2009: Hospital Association of Rhode Island announces that all hospitals and surgical centers have agreed to follow the same process to prevent errors in surgery.

July 1, 2009: Rhode Island Hospital and Newport Hospital join with the Joint Commission, a national accrediting agency, to deploy a problem-solving methodology to eliminate wrong-site surgery.

Oct. 22, 2009: A Rhode Island Hospital surgeon operates on the wrong finger during outpatient hand surgery.

Sources: Providence Journal archives and "A History of Wrong-Site Surgery in Rhode Island," by Dr. Robert S. Crausman and Bruce McIntyre, Journal of Medical Licensure and Discipline, Nov. 4, 2008.