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On November 23, a resident in training at Rhode Island Hospital began to drill into the right side of an 82-year-old woman's skull, although her brain was bleeding on the left side. Hospital staff discovered the error and closed the initial incision with a single stitch, then proceeded to carry out the surgery on the left side. The patient was reported to be unharmed by the error. But the mistake was the third in a year, following a full neurosurgery performed on the wrong side of a patient's brain in February and a similar mistake in August. The patient in the first operation was unharmed, but the patient in August died a few weeks after the mistake. In response to the death in August, the state ordered the hospital to implement new procedures to prevent such mistakes from recurring. These measures included making doctors verify surgery plans better ahead of time and an independent review of the hospital's practices. The review had not been completed as of the third mistaken surgery. According to Jay Wolfson, of the department of Public Health at the University of South Florida, the fact that three different doctors at the same hospital made the same mistake suggests a systemic problem. "There is no excuse for multiple episodes within the same discipline," he said. After the most recent mistake, the hospital announced a new policy for brain surgeries. "Effective immediately, all intra-cranial neurosurgery procedures will have an attending physician present for the entire procedure and the timeout process to verify site and side for significant procedures," the hospital said. In addition, another physician will be present to supervise the whole procedure. According to a study published in the Archives of Surgery, approximately 4 percent of non-spinal surgeries performed in a 20-year period were carried out on the wrong location. Related CounterThink Cartoons:
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