PROVIDENCE, R.I. (AP) – A doctor and two nurses at The Miriam Hospital involved in operating on the wrong knee of a patient last fall have been disciplined, state health officials said Tuesday. The error at the Providence hospital occurred Sept. 19 when the surgical team failed to visually verify which knee needed the procedure.

The wrong knee was draped and prepped for the surgery, known as a knee arthroscopy. The surgeon learned of the mistake after the procedure was complete, then went back and operated on the correct knee.

The Rhode Island Department of Health said Tuesday that one doctor and two nurses have been formally reprimanded for their roles in the wrong-site surgery.

The nurses also must participate in educational training on wrong-site surgeries and present some of the lessons to their peers.

After the botched procedure, the Providence hospital signed a consent agreement calling for it to change pens used to mark the surgery site so that the markings cannot be washed off during preparation for the surgery.

It also agreed to fix several problems related to “time-outs,” the period just before the surgery begins when hospital staff verify the correct patient and surgical site.

The hospital said in a statement that it regretted the error and has made multiple changes, including working with a national expert in patient safety.

“These changes are designed to encourage a culture of empowerment and accountability for the entire surgical team,” the hospital said.

Health Department Director David Gifford said it was important to make system-wide changes as opposed to sporadically punishing doctors and nurses.

“If we just sort of sanction someone and that’s it, problems will keep happening, unfortunately,” Gifford said. “This was not just about individuals. This was not just one individual who was a rogue individual who blatantly ignored (the rules) and did everything wrong.”

AP-ES-02-17-09 1807EST

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