A piece of drill bit left in a patient after an Aug. 4 surgery at Rhode Island Hospital has drawn the attention of the state's health department, marking the second time in the past year that surgical services at the Providence-based facility have come under review.

In a statement, hospital officials say the fragment was not accounted for at the end of the procedure, as is required by one of its policies. The debris was eventually discovered through diagnostic imaging and removed during an outpatient procedure performed 2 days after the original surgery, according to the statement. Hospital officials say they have apologized to the patient and completed a full investigation that resulted in undisclosed disciplinary action taken against the surgical team involved in the incident.

The hospital also notified the Rhode Island Department of Health and is cooperating with its investigation, notes the statement. A spokesman for the health department says it is partnering with the regional office of Centers for Medicare and Medicaid Services and will release the results of the examination once it is complete.

Janis Snyder, RN, clinical manager of the Adult and Children's Surgery Center of Southwest Florida in Ft. Myers, admits that the RIH event was an unusual occurrence, but "an appropriate surgical count of all pieces and parts according to AORN standards" should have prevented the oversight. She says surgical techs need to check a drill's integrity before it's handed to the surgeon and after it's removed from the surgical site. "Sometimes I believe techs don't feel comfortable confronting a surgeon about these types of issues," she says.

This isn't the first time RIH's surgical missteps have drawn unwanted attention. Surgeons there drilled into the wrong side of patients' skulls 3 times in 2007, a series of errors that prompted an investigation by the department of health and the launch of a statewide protocol designed to reduce avoidable errors by improving communication among surgical team members. In May 2009, a surgeon at an RIH-affiliated children's hospital started to operate on the wrong side of a pediatric patient's mouth during a cleft palate correction.

Then in October 2009, a surgeon at RIH began operating on the wrong finger during an outpatient hand procedure before catching the error and completing the case without further incident.

Weeks later, in response to the wrong-site surgery issues, the department of health fined RIH $150,000 and issued a compliance order. The order required the hospital to shut down elective surgery for 1 day to conduct a mandatory retraining and review of uniform surgical procedures with all surgical staff, continue clinical observation of surgical-site marking and time-out procedures for at least 1 year, install video and audio monitoring equipment in each OR, and immediately adopt and implement into practice statewide safety checklist protocols.

Daniel Cook

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