One operation went awry after an experienced brain surgeon insisted to a nurse he knew what side of the head to operate on, then got it wrong.
Another time, a doctor-in-training cut into the wrong side of a patient's head after skipping a pre-op checklist. In a third case, the chief resident started brain surgery in the wrong place, and the nurse didn't stop him.
All three mistakes happened at the same hospital in less than a year - Rhode Island Hospital, the state's most prestigious medical center and a teaching hospital for the Ivy League's Brown University.
The errors happened despite an explicit set of required operating-room precautions adopted by the medical profession a few years ago to prevent "wrong-site surgery" mistakes. Those measures include the use of checklists, "time-outs" to double-check that everything is correct, and indelible markers to show the surgeon where to cut.
"The problem's not going away," said Peter Angood, vice president and chief patient safety officer at the Joint Commission, an independent organization that accredits most of the nation's hospitals. "Organizations don't like to do this. It's complicated for them to do. Surgeons tend to resist it."
The mistakes at Rhode Island Hospital suggest that the precautions can still be thwarted by the human element - ego and overconfidence on the part of surgeons, and timidity on the part of nurses too afraid to speak up when they see something about to go wrong.
"There's a big cultural issue in most operating rooms where there's a hierarchical culture," said Diane Rydrych, assistant director of the division of health policy at the Minnesota Health Department. "If there's a culture where people are afraid to say anything to the surgeon because they're afraid they're going to get yelled at, that's a problem."
The Joint Commission gets about eight reports a month of wrong-site surgery, but hospitals are not required to report such incidents, and Angood said the real number is probably 10 times higher. (The commission received only five or six reports a month in 2002, before the precautions took effect, but attributes the increase since then to better reporting, not more errors.)
After the third mistake at Rhode Island Hospital, the institution was fined $50,000, ordered to tighten up its procedures and required to report to the state every time a doctor fails to follow the rules. The hospital also took unspecified "corrective action" against the doctors and nurses.