The Rhode Island Department of Health on July 17 announced that it had signed a consent decree with Kent Hospital of Warwick that places the hospital's interventional radiology department on probation for six months. The hospital has agreed to a series of staff training, inspection, and monitoring actions to address the state's concerns over interventional radiology procedures and protocols at the unit.
The disciplinary action comes after the hospital notified state authorities of two wrong-site interventional radiology procedures that occurred in June. In one case, a patient had a peripherally inserted central catheter (PICC) inserted into the incorrect arm. In another case, a patient had x-ray contrast media injected into the wrong hip. Neither of the patients involved were injured.
On July 8, Department of Health authorities issued a report based on onsite inspections that found that the department had failed to follow protocol in six out of eight cases reviewed. They also found radiology equipment that had not been inspected or had out-of-date inspections and the use of radiology equipment by unqualified staff. Authorities did not find any problems with the hospital's operating room or cardiac catheterization lab.
After the errors were discovered, the department was placed on 100% observation for a week, with the chief of radiology and two senior clinicians observing every procedure. The hospital also sent educators into the department to review correct procedure protocols, according to Sandra Coletta, president and CEO of Kent Hospital.
"The health and safety of our patients is the number one priority," Coletta said in a statement. "We are taking this opportunity to strengthen hospital policies that serve to protect our patients and guide our staff in the important work they do every day."
Under the terms of the consent agreement between Kent and the state, the hospital agrees to do the following:
- Hire a consultant to evaluate interventional radiology policies and protocols for compliance with national best practices.
- Observe and monitor the interventional radiology department and submit monthly reports to the Department of Health for six months.
- Contract with a patient safety organization.
- Provide continuing education for the radiology staff and develop an education plan for newly hired staff in the future.
- Provide proof of up-to-date inspections for all radiology equipment.
The two doctors involved in the wrong-site procedures are on staff with the hospital and are still working in the department; they are being reviewed by the Rhode Island Board of Medical Licensure to determine whether disciplinary action is needed, according to Coletta.
The action comes as the Department of Health has been promoting a statewide effort to reduce medical errors in hospital operating rooms. Regulators believe that the case illustrates that error-prevention techniques being adopted in operating rooms were not making their way into the interventional radiology department, according to Dr. David Gifford, director of the Department of Health.
"With the recent statewide focus of preventing medical errors in hospital operating rooms, this [case] is particularly concerning," Gifford said in a statement. "While we determined this issue is isolated to the interventional radiology department, the fact that the efforts in the operating room were not being adopted in the interventional radiology department is unacceptable."
The situation is a wake-up call for radiology, according to Coletta.
"There's a message here for radiology," she said. "Procedures and protocols that are followed in the surgery suite need to be followed in the radiology department, too."
By Kate Madden Yee
AuntMinnie.com staff writer
July 21, 2009
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