Rhode Island Hospital sets to make changes after several patient mix ups

PROVIDENCE, R.I. (WLNE) – On Friday, June 8, The Rhode Island Department of Health released information of four different reported mishaps with identification between February 2018 and March 2018, at Rhode Island Hospital.

The RIDOH and Rhode Island Hospital have entered into a Consent Agreement, after these mistakes took place. As a result, over the next year, system improvements will be made towards patient identification and procedure verification at Rhode Island Hospital.

The mishaps that occurred are listed as follows:

  1. February 21, 2018, Patient ID #2 underwent a computed tomography angiography of the brain and neck intended for another patient.
  2. February 26, 2018, Patient ID #1 was not correctly identified and as a result underwent an angiogram, intended for another patient.
  3. March 12, Patient ID #3 underwent a surgical vertebroplasty on patient ID #3’s C-6 which was intended to be done on C-7.
  4. March 16, Patient ID #8 underwent a mammogram of the right breast intended for another patient.

It is mentioned that “no patients had complications”.

“Whenever preventable errors occur in hospital settings, it is essential that we scrutinize those errors carefully and that facilities make the systems changes needed to ensure that they do not occur again,” said Director of Health Nicole Alexander-Scott, MD, MPH.

The press release outlines the Consent Agreement, which includes the following information:

  • Requesting and implementing the recommendations of the national hospital accrediting body, known as the Joint Commission, and putting in place process improvement methodologies developed by the Joint Commission.
  • Conducting facility-wide training on patient identification and procedure verification.
  • Scheduling a series of meetings with community emergency medical service (EMS) leadership and emergency department staff (among other staff) to identify opportunities for improvement related to patient identification.
  • Submitting to RIDOH policies and procedures related to access to electronic medical records, with a focus on policies related to the number of patients records a user can access simultaneously.
  • Hiring an external compliance organization to provide monitoring and oversight for at least one year.

The hospital has agreed to make a $1 million investment to improve the variation in their practices.

“We can and must do better and will focus on reducing variability and deviation in our practices. The more standardized our practices are, the safer they will become,” says Margaret M. Van Bree, MHA, DrPH.

The Rhode Island Department of Health says these incidents are “very concerning”, but they do their best to prevent similar occurrences in the future.