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October 26, 2010

The Rhode Island Department of Health has fined Rhode Island Hospital $300,000 for leaving part of a broken drill bit inside a patient’s skull after brain surgery, and that is not the only incident of a surgical tool left inside a patient recently at this hospital.

The agency released a copy of a letter sent to Timothy J. Babineau, MD, CEO of Rhode Island Hospital today from David R. Gifford, MD, MPH of the Rhode Island Department of Health. In the letter, the agency said that hospital staff failed to follow the hospital’s policy that dictated they x-ray the patient before removing her from the operating room when they knew the drill bit had broken and pieces were missing. The letter also said that this error placed the patient at significant risk of harm when she had a routine MRI the next day with the metallic piece of drill bit still in her head.

However, the Department of Health worried that this lack of following hospital policy is not what troubles them the most after the agency investigation at Rhode Island Hospital.

“Of even greater concern is the failure of the hospital to adequately address numerous reports by staff of problems they identified that could result in medical errors,” said the Department of Health’s David R. Gifford. “For example, staff reported that the surgical count process for sponges and medical equipment was often incorrect… yet we did not find any evidence that appropriate action was taken by hospital management to address this significant problem.”

Nurses also told the Department of Health investigators that the hospital never addressed complaints of an anesthesiologist not wearing his surgical mask in the operating room.

In a statement, Timothy J. Babineau, MD and CEO of the hospital said the drill bit incident occurred in August. He revealed another incident in July in which surgeons left forceps inside a patient.

The Providence Journal reports that Rhode Island Hospital had five previous surgical errors since 2007. In October 2009, a surgeon operated on the wrong finger, in May 2009 a surgeon operated on the wrong side of a child’s mouth, and surgeons operated in the wrong location during three separate brain surgeries in 2007.

In October 2009, Babineau told The Providence Journal that the mood in the department was “frustrated” and when asked if he thought there was something fundamentally awry at the hospital, he said, “I was wondering that myself.”

Dr. Babineau said in a statement today, “There is absolutely nothing more important to us, and no issue we consider more critical, than the safety and well being of our patients. We have made aggressive efforts to put the strongest, most effective policies in place to eliminate medical errors. But if we fail to adhere to these policies 100 percent of the time — we are falling short. And that is unacceptable and frustrating.”

“These findings combined with the findings related to prior wrong site surgeries, reflect a troubling pattern of disregard of policies designed to address patient safety and prevent medical errors,” Dr. Gifford of the Department of Health said.

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