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Neurosurgeon operates on wrong side of patient's head

Quality Improvement Monitor, August 10, 2007

As The Joint Commission reviews its standards to prevent wrong-site surgery, Rhode Island health officials are investigating why a neurosurgeon at a Providence hospital operated on the wrong side of a patient's skull, according to the Boston Globe.

Wrong-site surgery is "a persistent problem in American healthcare," despite years of efforts to prevent it, Peter Angood, MD, vice president and patient safety officer at the Joint Commission, told the paper. "No patient wants to have the wrong procedure, and we need to do whatever we can to prevent that."

The error last week at Rhode Island Hospital was the second time in 2007 that a neurosurgeon there performed a procedure on the wrong side of the head.

David Gifford, MD, head of the state's health department, told the Globe preliminary interviews indicate the hospital incorrectly applied at least part of The Joint Commission's Universal Protocol.

The Joint Commission held a summit on wrong-site surgery in February, but recommendations from the gathering have not yet been released, the paper reported.

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