St. Vincent Defends Role in Surgery Error, Questions Remain About Following Protocols

Thursday, August 11, 2016

GoLocalWorcester News Team

St. Vincent Hospital defends its role in a surgery gone terribly wrong. The Hospital said in a statement to GoLocal on Wednesday night said there staff did nothing wrong and that the error was caused by someone outside their staff.

Saint Vincent Hospital is under investigation by state and federal authorities following allegations that the hospital operated on the wrong patient, and removed the patient's kidney. 7News was first to report Wednesday that the Massachusetts Department of Public Health is reviewing the incident.

"This is a deeply unfortunate situation involving a patient misidentification that took place outside of our hospital and did not involve our employees. Our staff followed proper protocols in preparing for and performing the surgery, which was scheduled by the patient’s physician at our hospital," said Caitlin S. Lubelczyk, Marketing Manager at the Hospital.

But, many questions remain. Each year about 2,700 wrong side, wrong patient surgeries take place and correspondingly, the healthcare industry has developed stringent protocols to ensure that they do not occur.

SEE PROTOCOL BELOW

In the U.S. over a twenty-year period, 9,744 malpractice settlements for surgical "never events" were paid {1990 to 2010) totaling $1.3 billion. Of the settlements analyzed, approximately 6 percent of patients died, 32.9 percent of patients suffered a permanent injury and 59.2 percent of patients experienced temporary injuries, according to Infection Control & Clinical Quality.

In 2010, Rhode Island Hospital (RIH) was hit Tuesday with a $300,000 fine by the Rhode Island Department of Health for an August incident when, during neurosurgery, a small piece of a drill bit broke off and was left lodged in a patient's scalp.

The Department of Health conducted a joint investigation with the Center for Medicare & Medicaid Services (CMS) and discovered that the hospital is not actively ensuring that the operating room staff is following existing hospital policy.

RIH’s surgical count policy states that if a surgical tool or device is unaccounted for at the end of surgery, an x-ray of the patient should be done before the patient leaves the operating room to assure that the tool or device is not inside the patient. In the August incident, no x-ray was taken and the surgical count was documented as correct. “We found evidence they were not following their policies once again,” said Dr. David Gifford, then the Director of the Department of Health, “and the staff was reporting issues in the operating room that weren’t addressed.” Gifford added that operating room staff reported the anesthesiologist neglected to wear a mask during administration as well. “It’s a continued pattern of non-compliance with their own policies and procedures,” added Gifford.

Gifford noted in 2010 the $300,000 penalty is the department’s highest issued fine in state history, to the best of his knowledge, and double than the previous wrong-side surgery which occurred in September 2009, when a RIH surgeon operated on the wrong finger of a patient. Prior to that, the hospital made headlines in 2007 after three separate brain surgeries were done in the wrong location and when a surgeon operated on the wrong side of the mouth on a patient with a cleft palate.

If protocols were followed is unclear how such an error could be made. Healthcare privacy laws limit much of what the hospital or regulators can disclose, but what is reported is that a kidney was removed from the wrong patient.

"Saint Vincent Hospital is committed to providing safe, high-quality care to every patient who enters our doors. We are saddened that this incident occurred and our leadership continues to assure the individual receives the support and care needed," said Lubelczyk.

Related Slideshow: Patient Care Quality Issues in Central MA Hospitals

Prev Next

Athol Hospital

Issue at Hand: In the wake of a changing medical field, the nurses are unionizing with the MNA to have a voice in their hospital in regards to patient care.

“Our goal in forming a union at Athol was first and foremost to ensure that our patients are given the best care possible,” said Denise Raymond, an emergency department nurse at Athol Hospital and a member of the organizing committee. “We made this decision with the best interests of this community and this hospital in mind. As registered nurses we are responsible for the care we provide to our patients and now for the first time we will have a say in how we deliver that care.”

Prev Next

Leominster Hospital

Issue at Hand: The nurses delivered a petition to the hospital's CEO Deborah Weymouth asking to meet about concerns regarding cutting staff and merging the pediatric, labor and delivery, and maternity units. After initially agreeing to meet, Weymouth later refused and announced plans to press on with the proposed cuts and merger.

“We are shocked by our CEOs total disregard for the nurses and patients at this hospital as demonstrated by her refusal to hear what we have to say about changes that will impact the safety of our patients. “said Natalie M. Pereira, a nurse at the hospital and chair of the nurses’ local bargaining unit with the Massachusetts Nurses Association/National Nurses United. “She is the CEO, the buck stops with her and so does the responsibility for the safety of every patient in this hospital. It is all too clear that she cares more about the bucks than the patients at this facility, which only strengthens nurses’ resolve to speak out about the dangers of this plan.”

Prev Next

UMass Memorial: Memorial Campus

Issue at Hand: Nurses at the UMass Memorial's Memorial Campus have seen round after round of staffing cuts for not only nurses, but valuable support staff. They have also seen a closure of a medical floor, increased patient assignments, and the elimination of one-to-one sitters for high risk patients and the IV therapy team. Nurses have been ready to strike since 2013 and have cast a vote of no confidence in the Director of Nursing.

“These are the worst conditions at this hospital that I have seen since I began working here,” said Lynne Starbard, RN, Maternity Nurse at UMass Memorial Medical Center’s Memorial Campus and Co-Chair of the nurses local bargaining unit. “Dickson was a physician who came up in this system; my hope is that he realizes what he is doing to patients and nurses by continually cutting important programs and position.”

Prev Next

UMass Memorial: University Campus

Issue at Hand: Nurses at UMass Memorial's University Campus share the grievances of the Memorial Campus, which include round after round of staffing cuts as well as the closure of a medical floor, increased patient assignments, and the elimination of one-to-one sitters for high risk patients and the IV therapy team.

“I think that conditions are actually getting worse,” said Ellen Smith, RN, Critical Care Nurse at UMass Memorial Medical Center’s University Campus and co-chair of the nurses local bargaining unit. “We met this morning – we have a staff meeting once a quarter – and we spoke about how unsafe the hospital is for patients; it’s absolutely crazy. We feel that our unit is unsafe; it isn’t safe for patients or nurses.”

Prev Next

Marlborough Hospital

Issue at Hand: Nurses have been battling against staff layoffs and poor patient care condition. Nurses are particularly upset about cuts on the medical surgical floor, as well as the telemetry floor and the emergency department, causing nurses to care for as many as eight patients at one time. The hospital - in mid-August - hired a new Chief Nursing Officer but changes remain to be seen.

“The fact that they have hired a new chief nursing officer means nothing to us yet,” said David Schildmeier, Director of Public Communications with the Massachusetts Nurses Association. “If he is smart then he will immediately hire a number of nurses to benefit patient care. If he is hired and concerns of nurses aren’t addressed, then we will continue to fight and raise our concerns. The fact is this new hire needs to act more like a nurse than an executive or administrator.”