Kent commits to safety improvements after 4 medical errors

Kent Hospital, following a series of four errors made during medical procedures – three of which happened in consecutive months – has entered into a consent agreement with the Rhode Island Department of Health (RIDOH) where they will be responsible for spending $1.7 million to enact a plan to prevent such mistakes and ensure better patient safety.

The agreement was signed on June 21 by James Fanale, CEO of Care New England, which owns Kent Hospital, and signed on June 22 by Raymond Powrie, Interim President of Kent Hospital, and Nicole Alexander-Scott, the Director of the Department of Health.

Kent Hospital initially reported two instances of mistakes that occurred during surgical procedures in December of 2017 and March of 2018. The first incident in December involved the “re-excision of the right breast that was performed on the wrong area of the breast,” and in the second incident, medical personnel made an incision on the left side of a patient’s abdomen when it was supposed to be made on the right side during a nephrectomy – which is a procedure to remove a malfunctioning kidney.

Kent reported these two instances voluntarily on a Centers for Medicare and Medicaid Services (CMS) and State licensure survey and “timely responded” to the deficiencies in procedure that allowed these two incidents to occur, according to the consent agreement. RIDOH acknowledged this report in April of 2018.

While new policies were being implemented to prevent other similar incidents, however, the third and fourth instance of medical malpractice occurred – both of which involved leaving a guidewire used to aid the insertion of a catheter inside the patient following the procedure, one in April and one the following month in May. These types of incidents are known as unintended retained foreign object (URFO) incidents. In total, the four incidents happened over a six-month span.

In response, on June 13 Kent presented a 100-day “turnaround plan” expanding upon the policy changes they began following the first two incidents. This plan includes spending $1.7 million from Kent’s own revenues to research, organize and implement changes “to ensure patient safety and compliance with the plans of correction and applicable federal and state standards.” This will include elements of training, re-training and updating verification procedures to prevent URFOs.

As part of the agreement, Kent Hospital must report the four incidents to the Office of Quality and Patient Safety and begin to implement any of their recommendations within 30 days. The hospital must also hire an independent expert compliance contractor to monitor that they are taking the required steps and report all related activities to RIDOH as they occur. Failure to do so means RIDOH could take punitive measures in accordance with state law. The hospital has not been penalized at this time.

Kent must also implement one or more “Targeted Solutions Tools” as set by the Joint Commission Center for Transforming Healthcare, a non-profit organization that analyzes medical care incidents and proposes methods to prevent them from occurring.

All monitoring of Kent’s improvement plans will remain in place for one year or until all the terms of the consent agreement have been met.

“The trust that the community and our patients place in us when they seek their care at Kent Hospital and across CNE is a great privilege and also a great responsibility,” said Fanale and Powrie in a joint statement. “We believe we have a health care system devoted to providing tremendous outcomes for our patients who need a wide array of care. We continue to focus our attention on improving quality at all of our facilities that are considered to be leaders both in the industry and in the community.”

In the statement, Fanale and Powrie ensured that “Kent Hospital and Care New England have begun an active and aggressive improvement plan that is resulting in a complete and thorough review of our safety culture and practices, hospital-wide education, retraining, and recommitment to a level of excellence that will be unsurpassed.”

The statement says that the hospital had already begun implementing such improvements following the first two incidents, which included “disciplinary action, policy and procedure review, competency assessment, auditing of compliance with policies and protocols, and prospectively maintaining a constant state of renewed diligence towards adherence and compliance.”

Fanale and Powrie expressed their willingness to continue to strive towards higher standards.

“Clearly, based on our own experience and the findings of the Department of Health, we still have more work to do,” the statement concludes. “We want to assure the people of our region that we are committed to this work and to move forward quickly on this journey to excellence that is increasingly the major focus across the health care landscape locally and nationally. It is the single most important thing we can do for those who trust us with their care.”