Rhode Island Hospital has been fined $300,000 for a surgical error that left a piece of broken drill bit in a patient's skull. The Rhode Island Department of Health has twice previously fined the hospital, but this is the largest fine it has received thus far.
The hospital acknowledged that a small piece of a drill bit broke off during neurosurgery and was left in a patient's scalp on August 4, 2010. The piece was one quarter of an inch long, and it was discovered the day after the patient's surgery during a routine diagnostic imaging exam. The piece was removed on August 6, and the patient was discharged that day, reported The Providence Journal.
Rhode Island Hospital policy states that a patient must undergo an X-ray before leaving the operating room if any surgical tool is unaccounted for after a procedure. After investigating the incident, the Rhode Island Department of Health and the U.S. Centers for Medicare & Medicaid Services (CMS) found that the patient was not X-rayed as required and that the hospital is not actively ensuring that operating-room staff follows established procedures, according to a Department of Health news release.
Further, the Department of Health discovered that the hospital has not responded to multiple reports from staff that equipment was not correctly counted after surgery. The director of the Department of Health, David R. Gifford, said there is a "troubling pattern of disregard for established policies that are designed to protect patient safety and prevent medical errors."
The Providence Journal reported that, in addition to the fine, the CMS has asked the Department of Health to inspect all areas of the hospital and ensure that it is in compliance with CMS's Conditions for Participation for Medicare. Licensing boards are also investigating a nurse and two doctors involved in the incident for possible disciplinary action.
Source: Rhode Island Hospital fined for drill-bit piece left in head, Neurosurgery error prompts state investigation of Rhode Island Hospital