“Three strikes and you’re fined”; this is the story of Rhode Island Hospital after three different brain surgeons operated on the wrong parts of the heads of three different patients. Rhode Island Hospital is the state’s most prestigious medical center and a teaching hospital for the Ivy League’s Brown University. All three mistakes happened in less than a year. A fourth case involved a surgeon who operated on the wrong side of a patient with a cleft palate. How does a surgeon miss a cleft palate?
On October 22, another wrong-site procedure took place when a patient was having elective surgery on two different fingers of the right hand. Remarkably, both procedures were performed not only on the same hand, but on the same finger. By now, you should be asking yourself “how could this happen”?
State Health Director David R. Gifford had this to say:
“This pattern of surgical errors is completely unacceptable and must be corrected to protect the safety of all patients at the hospital.”
Equally alarming is that the surgeons involved in these errors are (or were) highly regarded. The most well trained doctor who has done the same or similar procedure hundreds of times needs to follow protocol. Surgeons are required to follow a three-step process called the “Universal Protocol” to ensure they are about to do the correct operation, usually via a checklist. Obviously, protocol is loosely followed, if at all, at Rhode Island Hospital.
Fortunately, none of these wrong-site surgeries resulted in fatalities. The Hospital has been slapped with a $150,000 fine, required to install video cameras in all its operating rooms, and must assign a clinician, not part of the surgical team, to observe all surgeries at the hospital, for a period of not less than one year. The hospital will, apparently, use video of these procedures as a monitor and training tool.
Will these measures work? They might decrease mistakes and increase safety in the operating room, but given the hospital’s recent track record, slapping the perpetrators with a fine and making them “promise” to follow safety protocol does not seem adequate to this observer.
The hospital must also conduct a mandatory training and review of the uniform surgical procedures with all surgical staff, and implement the safety checklist. Obviously, these critical safety procedures were not being used or were being misused. What happened to patient care and safety? How would you, as a juror in these victims’ cases, handle these medical mistakes and victims’ compensation? Would it anger you to find out that your verdict was thrown out in favor of a lower damage cap? Where is adequate punishment? Where is justice?
These questions lead me to the ultimate question I repeatedly ask in many of my posts: Why do congressional conservatives and the citizens who support these politicians seek to punish the victims of medical error rather than the perpetrators? Tort Reform, a fancy name for placing a damage cap on serious verdicts for serious injuries or fatalities at unreasonably low numbers, will do nothing to improve safety in the operating room. It will further encourage those responsible for committing medical errors to be less responsible. Why? Because there will be little or no consequence for mistakes made. Insurance companies will get a financial windfall and the public sector, in the form of increased taxes for assuming the burden of the wrongdoers, will take the financial hit. Is that what fiscal conservatives stand for? They do if their hands are in the pockets of insurance companies and big pharmaceutical companies. While insurance companies receive a “get out of trouble” free card, the taxpayers get the bill. Is this what the American people want?
Rhode Island Hospital should be a wake-up call to all who favor placing damage caps and other anti-justice restrictions on patients and their loved ones as they seek to recover full and fair compensation for injuries and losses caused by negligent medical and hospital personnel. Hospitals and doctors must be held fully accountable for inadequate care. It is time we address the real problem–preventable medical errors. The easiest way to reduce the cost of medical malpractice is to prevent or reduce the incidents of medical errors; the system will not repair itself by punishing the victim a second time. Stop blaming the victims; hopefully the situation at Rhode Island Hospital has sent this loud and clear message to Congress as they continue to ponder changes in our health care system.
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