A surgeon operated on the wrong side of a patient's head after a CT scan was placed backwards on the lightbox, Rhode Island's Providence Journal reported Wednesday.
The mixup made it look as though the patient had bleeding on the left side of the brain, rather than the right. As a result, the surgeon drilled two holes on the left side of the patient's skull, found no bleeding, and then repeated the procedure on the other side. The blood was successfully drained from the right side, and the patient suffered no ill effects save for the incision, Rhode Island Hospital spokesman Jan Bruno told the newspaper.
The operation occurred on December 12, 2001. Hospital procedures were in place to prevent such errors, including a final check of the surgery site, and pen-marking of the site. However, these procedures were not followed, the article said.
According to a "report of correction" filed Tuesday with the state health department, a surgical resident told the staff to position the patient with his left side up. Once the patient was draped, no one could tell that the wrong side of the patient's head was exposed.
Six hospital staff members were involved in the accident, including the surgeon, two surgical residents, the operating-room nurse, the operating-room technologist, and the certified registered nurse anesthetist. All of them have been referred to their licensing boards for investigation, the article said.
The hospital is now analyzing the root causes of the accident, and will establish new procedures, retrain the staff, and monitor the results of training, the article said.
By AuntMinnie.com staff writersJanuary 17, 2002
Copyright © 2002 AuntMinnie.com
