Surgeon, Nurses Reprimanded for Surgical Error

Projo reports that the Rhode Island Dept. of Health has reprimanded a doctor and two nurses for their roles in the wrong-site surgery at Miriam Hospital in September. The team operated on the wrong knee of a patient undergoing an elective, outpatient procedure. According to the Health Department investigation, the surgeon, Dr. Robert M. Shalvoy, had correctly marked the surgical site. "But a nurse, Susan Dilibero, failed to look for the surgical site marking before preparing the knee, and draped the wrong knee." Then, in the "time out" just before surgery, Shalvoy, Dilibero and a nurse anesthetist, John Duhamel, all failed to verify that the knee they were about to operate on was the correct one, although Dilibero documented that the site had been verified.