Wrong knee operated on even after new protocol at RI hospital

Patient Safety Monitor Insider

September 24, 2008

The state of Rhode Island suffered its eighth wrong site surgery within the past decade, when Miriam Hospital operated on the wrong knee of a patient last week, The Providence Journal reports.

Prior to surgery, Miriam’s new protocol to prevent such errors was followed. The surgeon marked the correct knee "yes” and in the operating room a “time-out” was taken, where six people agreed the correct knee was marked. The error was noticed by the patient upon waking in the recovery room, with pain still in the bad knee.

Miriam reported the incident to the state's Health Department, which is now considering implementing statewide regulations to address the issue.

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