Three Rhode Island Healthcare Professionals Sanctioned In Wrong-Site Surgery Case

Ruzanna Harutyunyan's picture

The Rhode Island Department of Health (HEALTH), Board of Medical Licensure and Discipline (BMLD) and Board of Nursing, has completed its investigation of the health professionals involved in the wrong-site surgery done at The Miriam Hospital (TMH) in September 2008.

Three healthcare professionals – one physician and two nurses, received a sanction of reprimand. In addition, the two nurses must participate in patient safety activities on the prevention of wrong-site surgeries and present at least one “lessons learned” to their peers.


Upon initial investigation of the incident in the fall, several problems in the hospital’s surgery program were identified, including failure to follow TMH’s policy to visually inspect the surgical site during the time-out, (which is the last step prior to starting surgery to verify the correct patient, surgery and surgical site) to use indelible ink to mark the site and to verify the original source of information related to the surgery and site

“This finding completes HEALTH’s investigation of this incident,” said Chief Administrative Officer of the Board of Medical Licensure and Discipline Robert S. Crausman, MD, MMS. “Although we determined that systemic issues contributed to this wrong-site procedure, it does not absolve healthcare professionals from individual accountability to meet acceptable standards of practice. This finding also emphasizes that the entire healthcare team has responsibility for consistently practicing patient-safety policies.”

“Nurses play a critical role in ensuring everyone follows protocol and in creating a culture of patient safety,” said Director of Nurse Registration and Nursing Education Pamela L. McCue, RN, MS. “While we need to hold all nursing professionals accountable for their actions, our primary goal is to prevent this type of incident from reoccurring.”