Wrong-sided Brain Surgery Cases at Rhode Island Hospital

In November 2007, the Rhode Island Department of Health reported it had fined a hospital $50,000 and recorded a formal reprimand after a receiving a report of three patients undergoing brain surgery on the wrong side of the patient's head.

The three cases included a case where a chief resident began brain surgery on an 82-year-old patient, as well as a case earlier in the year where a different doctor who also operated on the wrong side of their patient’s head. Both of these patients were reported to not have suffered any adverse outcomes after the incorrect surgery.

However, in August 2007, a patient died a few weeks after a third doctor made the same error. After the August surgery which led to the death of the patient, the state ordered the hospital to comply with protocols to make sure a mistake of this type would not happen again, including requiring the hospital to follow a neurosurgery checklist that includes information about the location of the surgery and a patient's medical history, and to put in place a plan to train staff on the new checklist.

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