Corporate Compliance

Three RI healthcare professionals disciplined in wrong-site surgery case

Healthcare Auditing Weekly, February 24, 2009

The Rhode Island Department of Health Board of Medical Licensure and Discipline reprimanded three healthcare professionals in a wrong-site surgery case that occurred in September 2008 at the Miriam Hospital in Providence, according to a state press release.

The Board disciplined Susan Dilibero, an operating room nurse, for preparing the wrong knee for an arthroscopic surgery to repair a tear in the 60-year-old female patient’s left meniscus. Dilibero allegedly documented that she verified the surgical site immediately prior to the surgery, even though, she failed to do so, according to the press release. 

The Board also found Robert M. Shalvoy, the orthopedic surgeon, and Robert Duhamel, the nurse anesthetist, guilty for failing to verify the surgical site prior to the surgery.

During investigation, the board found several problems in the hospital’s surgery procedures, including a failure to follow the hospital’s policy. Hospital policy requires the surgical staff visually inspect the surgical site during the “time-out” period (the last step before starting surgery to verify the correct patient, surgery, and surgical site). Surgery staff also did not use indelible ink to mark correct surgery sites or verify the original source of information related to the surgery and site, according to the press release.

In addition to giving the sanction of reprimand, the board is also requiring Dilibero and Duhamel to participate in patient safety activities on the prevention of wrong-site surgeries and give a presentation to their peers expressing the lessons they have learned.

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