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The Knucklehead of the Day award

Today's winner is Miriam Hospital in Providence Rhode Island. They get the award for the following-

A doctor at the Miriam Hospital this morning operated on the wrong knee of a patient undergoing arthroscopic surgery for arthritis and an injury.

The mistake was first noticed by the patient when she regained consciousness, according to Dr. Kathleen Hittner, hospital president. The hospital then performed the surgery on the correct knee, and the patient is doing well, Hittner said.

Miriam Hospital is part of the Lifespan hospital group, which includes Rhode Island Hospital, where three wrong-site surgeries occurred last year. Hittner said that Miriam had recently instituted policies intended to prevent these very types of errors.

Interviews conducted today indicated that all protocols had been followed, including marking the site and pausing before surgery starts to ensure that the team was about to do the right thing, according to Hittner. Although the correct knee was marked, the wrong knee was draped for surgery, and six people in the operating room somehow did not notice it was the wrong knee, she said.

Hittner said she felt "tremendous sadness, sorrow" over the incident. "I can't believe it actually happened to us because we worked so hard to prevent it," Hittner said. "We're really sorry that this happened. We're going to work hard to make sure it never happens again."

You're sorry about the mistake, but refuse to name the doctor. How sorry is this hospital really? Patients should be warned about this physician. The AP article makes it clear the hospital is refusing to name who operated. Even if readers disagree with me about the physician being named, the hospital was negligent because their operating room personnel failed to do their jobs properly, and it isn't the first time it happened in the last 12 months. That's good enough for me to name Miriam Hospital in Providence Rhode Island today's Knucklehead of the Day.


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Comments (10)

When I had my knee surgery,... (Below threshold)

When I had my knee surgery, not only was the knee marked with a large "X", I was also required to point out the knee to the surgeon before they put me under. Just to be a wiseass, I asked the surgeon if I'd be able to play the violin after surgery. He said 'sure'. I replied, "Neat, I've never played one before". Hee hee.

Knee surgery is one thing..... (Below threshold)

Knee surgery is one thing... but I had a friend who in the 60s' had his healthy kidney removed instead of the diseased one.

Needless to say his life was shortened. It would be a shame to have to have patient advocates present during surgery wouldn't it?

I'm okay with the hospital ... (Below threshold)

I'm okay with the hospital not naming the surgeon. He should suffer consequences for this (and I'm sure he will) -- but it would be a waste to just throw away his years of training like that.

On a more personal note, cases like this always make me shudder just a bit. I had testicular cancer a few years ago, and the first operation was to remove the cancer-riddled testicle. At the time, I thought I was joking when I made sure each nurse, orderly, and doctor in the room knew which testicle was coming off and which was not. Every time I hear a story like this, I'm glad I did make a point of it, even if they thought it was silly.

Ran an EMS call last week a... (Below threshold)

Ran an EMS call last week and a lady was transported to the ER and admitted. It's a good thing her husband stayed with her. The Doctors came to her room and were discussing the Stents in her arteries. Her husband went off on them since his wife had never had surgery for anything. Wrong xrays could have cost the lady her life. Hospital workers are now like the aircraft we fly on, built/trained by the low bidder.

The attempts to improve saf... (Below threshold)

The attempts to improve safety in the medical system are still band-aid partial efforts that will be pointless unless there is a complete overhaul of how we do business as usual. I could rant about this for 5000 lines and only be started. The cultural changes that are necessary, along with procedural, legal, and systemic changes have been bucked by organized medicine, medical insurance and medical corporations more often than accepted and rarely embraced. Errors will always occur, but in a competent system they will be trapped. It sounds like these folks knew how to go through the motions but didn't know how to really effect the safety systems correctly to make them work.

Take a page from aviation safety as it evolved from the post WWII era to the 70's, and beyond. We're still practicing medicine like the airlines flew airplanes in the early fifties, with a few notable exceptions who are somewhere in the early 70's. Until there is real malpractice reform that mirrors air safety approach to reporting and investigating mishaps, then acting on the findings, there will be no real improvement in medical system safety. Our current tort system encourages a secretive every man and woman for themselves approach that only enriches the leaches, inspires ineffective and expensive reactions by medical providers and health care systems, and unreasonably increases costs without increasing safety.

rant over and out

"Although the correct k... (Below threshold)

"Although the correct knee was marked, the wrong knee was draped for surgery, and six people in the operating room somehow did not notice it was the wrong knee, she said."

Simple solution... endow all surgeons with Supermen-like X-ray vision. 'Cause obviously these bimbulbs in marking the "correct knee" did so on the UNDERSIDE!

She sorry this happened to ... (Below threshold)

She sorry this happened to US? It happened to the patient.

10:1 the patient gets bille... (Below threshold)
Jason Author Profile Page:

10:1 the patient gets billed for both knees.

Sounds like some $10/hour o... (Below threshold)

Sounds like some $10/hour orderly decided to cover up the scribbling of the patient`s child to avoid embarassment, leaving the clean one uncovered.

Silliness aside, I do wonder how this could happen. Especially considering it is protocol to pre-mark the area, why did the surgical team not notice there were no markings?

OTOH, I do have one fond memory of Miriam Hospital. While there for an evaluation I discovered that the ER waiting area, closed at night (RIHospital and Pawtucket Memorial are each about two miles off in different directions so this is not all that bad), was nonetheless accessible from inside the hospital so I was able to get a (FREE yet!) cup of coffee.

OMG, I had two knee surgeri... (Below threshold)

OMG, I had two knee surgeries done at this very hospital back in december of '88 and March of '89...lol.






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