The Rhode Island Hospital surgeon who started operating on the wrong side of a child’s mouth last month did, in fact, mark the outside of the child’s face –– but marked the wrong side. The doctor didn’t ask anyone else to verify the marking, and then covered it with surgical drapes. Those actions were contrary to hospital policy.

Those are among the findings of the Health Department’s investigation of what went wrong during the surgery to correct a child’s cleft palate on May 11. The results were made public this week.

The procedure involved removing a piece of bone from the child’s hip and placing it in the roof of the mouth. The resident who harvested the bone from the right hip noticed that the surgeon was operating on the left side, the wrong side. The operation stopped and the surgery was then correctly completed on the right side.

Michael S. Varadian, the Health Department official who oversees regulatory functions, said in an interview that typically in such surgeries, the bone is harvested from the opposite side from the surgical site in the mouth. In this case, at the patient’s request, the bone was coming from the same side, and that is what may have led to the doctor’s confusion, Varadian said.

The central problem, however, was that the operation was taking place inside the mouth, which cannot be marked. Hospital policy does not require marking surgical sites within orifices –– but was not clear on exactly how to verify them before surgery.

The surgical team followed the existing protocols correctly, conducting a “time-out” in which everyone agreed that the surgery should take place on the right side of the mouth. Even so, the doctor began operating on the left side.

“The hospital is working on a script that will be used in such situations to ensure the site is verified consistently,” said Dr. John B. Murphy, the hospital’s vice president and chief medical officer.

Varadian said that in cases where the site cannot be marked, there should be a procedure specific to those situations.

The Health Department’s report noted that the surgeon and other surgical staffers said they felt rushed during the procedure. “In any hospital, any surgical site, you don’t get a sense of peace and calm,” Varadian said. In this case, he said, “The surgery started late and they were trying to catch up.”

In a busy medical center, Murphy said, it’s inevitable that the staff will sometimes need to hurry after unexpected problems have caused delays. Murphy said he believes that the feeling of being rushed was not a major contributor to this error.

The Health Department’s investigation also found that the surgical staff were not always up-to-date on changes in policies and were confused about which policies were the most recent. The department faulted the hospital for failing to “make provisions for ongoing education for all personnel that includes written evidence that demonstrate competencies….”

Murphy said that policies must be updated periodically, often in response to changes in regulation from the Joint Commission, Health Department or other accrediting agencies. In the future, Murphy said, “We need to educate the staff in multiple ways to accommodate different learning styles and also require them to more fully demonstrate that they understand and can follow any new policy.”

Immediately after the incident, the hospital held seven meetings in seven business days with members of the surgical teams. Instead of having doctors meet with doctors and nurses meet with nurses, the hospital grouped people by specialty, such as orthopedic surgery or cardiovascular surgery. During those meetings, Murphy said, “Every member of the group spoke freely and constructively about how to improve and clarify procedures.”

The hospital also offered an anonymous online survey in case anyone felt hesitant to speak. “The survey,” he said, “yielded no new information beyond what we had heard at the meetings.”

Varadian said he attended some of those meetings. “It was refreshing to see that everyone was speaking up and offering helpful suggestions,” he said.

The mouth-surgery error was the fourth wrong-site surgery at Rhode Island Hospital since 2007. Varadian said the hospital staff took it hard. “Most of the staff feels terrible. ... I’ve had to go in and lift people’s heads and say ‘you’re not a terrible person,’ ” he said.

Murphy added that people go into health care because they want to help others. “Errors such as this are devastating to the entire staff,” he said, “and everyone is highly motivated to prevent another one.”

The Health Department this week accepted the hospital’s “plan of corrections” to fix the deficiencies the department had found, and Varadian said he will monitor to make sure the plans are carried out. Additionally, the state Board of Medical Licensure and Discipline is continuing its investigation of the surgeon.

ffreyer@projo.com