In an incident that marks the fifth wrong-site surgery reported in a Rhode Island hospital since 2007, an oral surgeon correcting a child???s cleft palate on May 11 at the Hasbro Children???s Hospital in Providence, R.I., began to operate on the wrong side of the patient???s mouth before discovering the error.

After correcting the error, the surgeon preformed the procedure "with good results," says Timothy J. Babineau, MD, MBA, FACS, president of Rhode Island Hospital, with which Hasbro is affiliated, in a published report. "The patient is in good condition and we do not anticipate any further complications related to this error."

The attending physician in the case has been referred to the state???s board of medical licensure and discipline, according to the Rhode Island Department of Health, which has been interviewing surgical staff members to investigate the cause of the error. "Preliminary findings of the hospital???s surgery program," says the department, "include failure to follow hospital policies, inconsistent interpretation of the time out policy, inadequate ongoing physician and nurse training about policy revisions, inadequate hospital-wide prospective assessment of the time out policy as it applies to specific surgeries (e.g. oral surgery, multi-site surgery, vaginal surgery) and inadequate identification and reporting of ???near misses??? by physicians, nurses and OR staff."

Says state health director David R. Gifford, MD, MPH, "As in most cases, this is not the fault of one individual nor is this fixed by just introducing a checklist."

Last September, a surgical team at Providence???s Miriam Hospital — like Hasbro and Rhode Island Hospital, a member of the Lifespan group of hospitals — performed an arthroscopic surgery on a patient???s incorrect knee. And a chain of errors led surgeons to drill into the wrong sides of patients??? skulls on 3 occasions at a Rhode Island hospital in 2007.

—David Bernard