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Analysis

Rhode Island Hospital Reaches $1M Agreement After 4 Patient Mix-Ups

By Steven Porter  
   June 11, 2018

A mammogram and other imaging services were performed on the wrong patients earlier this year, and one patient underwent surgery on the wrong part of the spine.

Providence-based Rhode Island Hospital reached an agreement with the state after four patients were subjected to incorrect tests and procedures in four different mix-ups within a month.

The hospital agreed to invest no less than $1 million in remediation efforts to improve its patient identification and verification systems and procedures, and the state's Department of Health agreed to forgo any regulatory action for the four incidents.

This case demonstrates how misidentifying patients can carry significant financial ramifications for hospitals and health systems, even when the errors do not appear to cause medical complications in the patients affected.

In a statement, the hospital said it began implementing its plan of correction immediately after identifying the incidents and has "dedicated thousands of staff hours and committed other resources to this matter" in recent weeks, noting that 685 active doctors, nurses, technicians, and other staff members from the radiology department have participated in a forum to improve care.

"Rhode Island Hospital is committed to adhering to all the requirements established by the Department of Health to help prevent errors in the future and will continue to work closely with the Rhode Island Department of Health on this matter," the statement said. "Mandatory audits of processes will also be implemented to ensure that changes become permanent solutions."

The four incidents in question are summarized in the hospital's consent agreement with the state:

  • February 21: A patient underwent a computed tomography angiography (CTA) scan of the brain and neck that had been intended for a different patient.
     
  • February 26: A patient who was not correctly identified underwent an angiogram intended for a different patient.
     
  • March 12: A patient underwent surgery on the wrong part of the spine.
     
  • March 16: A patient underwent a mammogram intended for a different patient.

Regulators conducted an unannounced survey then issued states of deficiency on March 29, according to the consent agreement.

In addition to the $1 million investment, the agreement requires the hospital to request written recommendations from The Joint Commission's Office of Quality and Patient Safety on how to prevent problems like those that led to the four incidents outlined above. The agreement, which lasts for one year, also requires the hospital to hire an independent compliance contractor.

"While Rhode Island Hospital is a national leader in patient safety and quality, we are not perfect," Rhode Island Hospital President Margaret M. Van Bree wrote in a memo to staff, as the Providence Journal reported. "When mistakes occur, we must acknowledge them and act immediately to improve care."

The agreement was announced Friday, as the Journal reported.

Steven Porter is editor at HealthLeaders.


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