By Felice J. Freyer; Journal Medical Writer
The decision converts what had been a voluntary license surrender by a neurosurgeon into a full-fledged two-month suspension.
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Dr. J. Frederick Harrington, the neurosurgeon, bears most of the blame for operating on the wrong side of a patient’s head at Rhode Island Hospital in July, a Health Department investigation has concluded.
Nevertheless, the state has allowed Harrington to resume practicing surgery, with no restrictions, effective last Wednesday. He had voluntarily stopped doing surgery shortly after the error.
The decision last week by the state Board of Medical Licensure and Discipline converts what had been a voluntary license surrender into a full-fledged suspension (from Aug. 2 to Oct. 10), the most severe sanction the board has ever issued for a wrong-site surgery, according to Dr. Robert S. Crausman, chief administrative officer. That sanction will be “attached to this doctor for the rest of his career,” Crausman said.
Wrong-site surgeries often involve a cascade of errors by many people in a hospital, but in this case most of the blame lies with Harrington, Crausman said. “His error was the primary cause of the wrong-site surgery,” Crausman said.
Harrington failed to check the CT scan images of the patient’s brain, relying instead on his memory, and also failed to pause and make sure he was right when someone in the operating room questioned him.
Crausman noted that nonetheless there were “systems issues” at Rhode Island Hospital that contributed to the error. The July incident was the third wrong-side surgery at the hospital in six years, all involving neurosurgery. This pattern prompted the Health Department to order immediate changes and monitoring at the hospital.
After the incident, Rhode Island Hospital suspended Harrington’s privileges, and Roger Williams Medical Center and Our Lady of Fatima Hospital followed suit. Spokesmen for all three hospitals said on Friday that Harrington’s privileges remain suspended.
But Robert Goldberg, Harrington’s lawyer, said he expects Harrington to regain his privileges at every hospital and resume his full practice. Goldberg said that the state had concluded that Harrington is “a good and fit physician.” It “speaks volumes,” he said, that the medical board restored his license without restrictions.
“The doctor more than anybody wishes the incident didn’t happen,” Goldberg said, calling Harrington a highly competent neurosurgeon.
Told of Crausman’s comments, Goldberg asserted that Harrington never sought to evade his responsibility for the error. “He was the captain of the ship,” Goldberg said, but added, “Ask every doctor in the state if they ever made a mistake. Who hasn’t? It can happen with any physician any time and any place.”
In Harrington’s case, it happened more than once. In September 2006, he also operated on the wrong side of a patient’s head at Roger Williams Medical Center, but the Health Department did not sanction him because of mitigating circumstances.
In the most recent incident, on July 30, an 86-year-old man came to Rhode Island Hospital three days after a fall. He was found to have bleeding on the brain, and as he started to do poorly in the emergency room, he was transferred to the operating room for emergency surgery. Neither the patient’s medical history nor the consent form specified which side needed the surgery. When a nurse pointed out that the information was missing, Harrington filled in the blanks, relying on his memory rather than consulting the CT scan.
He cut open the wrong side. As soon as he realized the error, he operated on the correct side. The patient died a few days later, but the medical examiner has yet to determine whether the surgical error contributed to his death.
Meanwhile, Rhode Island Hospital has been studying the incident and instituting changes to prevent a similar mistake from happening again, said Mary Reich Cooper, vice president and chief quality officer for Lifespan, the hospital’s parent company.
A new process requires the same safety checks for emergency surgery as for elective surgery, including checking the patient’s identity and consent forms, and stopping to verify that the doctor is about to perform the right procedure on the right part of the right patient. In the past, Cooper said, people bypassed this process because “they were afraid that those precious minutes might make the difference between life and death.” In fact, those safety steps take little time and only in rare cases can skipping them be justified, she said.
The hospital has also instituted a new “structured communication” between emergency room nurses and operating room nurses to ensure that all the necessary information is conveyed.
And it has set computers in the operating room to keep necessary images, such as CT scans, displayed constantly, so the doctor doesn’t have to call them up. In the past the computers would “time out” to protect patient privacy. But since everyone in the operating room is involved in caring for the patient, such periodic shutdowns were ruled unnecessary.
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(c) 2007 Providence Journal. Provided by ProQuest Information and Learning. All rights Reserved.
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