Ep 60-Never Never Land: Rhode Island Hospital's Decade of Surgical Scandals

A hospital can have world-class branding and still be dangerously broken where it counts. We’re heading to Rhode Island Hospital, a major teaching hospital tied to Brown University, to follow a decade-plus trail of “never events” like wrong-site surgery, wrong-patient procedures, and failures so basic they sound unreal until you see the record.

If you care about patient safety, hospital accountability, and how healthcare systems fail, this one will stick with you. Subscribe, share with a friend, and leave a review so more people can find the show and join the conversation.

Resources: 

https://www.golocalprov.com/news/a-decade-of-surgery-problems-plague-rhode-island-hospital

https://www.nbcnews.com/health/health-news/third-wrong-sided-brain-surgery-r-i-hospital-flna1c9463696

https://www.cbsnews.com/news/ri-hospital-made-3-brain-surgery-errors/ 

https://www.seattletimes.com/nation-world/ri-hospital-fined-150000-in-wrong-site-surgery/

https://meridian.allenpress.com/jmr/article/94/4/6/437143/A-History-of-Wrong-Site-Surgery-in-Rhode-Island

https://www.rhodeislandpersonalinjuryattorneyblog.com/wrong-site-surgeries-at-rhode-island-hospital-medical-malpractice-attorney/

https://thepublicsradio.org/article/25m-awarded-ri-couple-malpractice-rhode-island-hospital/

https://www.foxbusiness.com/markets/jury-says-rhode-island-hospital-should-pay-25m-in-largest-negligence-verdict-in-state-history

https://www.robertkreisman.com/medical-malpractice-lawyer/jury-enters-25-59-million-verdict-failure-identify-treat-intracranial-pressure-causing-permanent-devastating-injuries/

https://www.expertinstitute.com/resources/insights/61-6m-jury-award-holds-doctors-accountable-for-preventable-amputation/

https://medicalmalpracticelawyers.com/40m-rhode-island-medical-malpractice-verdict-loss-leg-due-medical-negligence/

https://www.decof.com/results/

https://www.tapinjury.com/news/40-million-awarded-rhode-island-hospital-medical-malpractice-suit/

https://patientsafetyj.com/article/156001-wrong-site-surgery-a-study-of-664-events-from-237-facilities-across-a-10-year-period

Transcript

Cold Open And Life Updates

SPEAKER_01 0:10

Amanda.

SPEAKER_00 0:18

Hey, how the heck are ya? Feeling groovy after that intro.

SPEAKER_01 0:23

Okay. We're nothing if not groovy girls. We groovy girls. Oh, do you remember girl were you little when groovy girls were out? Because I'm I mean you're a lot younger than me, but I just remember. No, I don't know what that is. You don't know groovy girls? Okay. They were like these rag dolls, but they were super groovy. And they had like little polyester outfits and disco boots and stuff, and my kids were really into them. They were super cute. And you could get them like bunk beds and like overpriced.

SPEAKER_00 0:48

Your kids were into them? What? So I was too old for them.

SPEAKER_01 0:52

Maybe slightly, but not much.

SPEAKER_00 0:55

I was like, I'm I thought you were gonna say like when you were younger, and then you pop in your kids. I'm like, well, no, then I was too old for them.

SPEAKER_01 1:04

You youngsters these days, you all just meld together.

SPEAKER_00 1:07

So much older than your kids.

SPEAKER_01 1:10

I know. I'm not that I wonder. Well, let's I was gonna say, let's figure out if you're closer to their age or mine, but then I was like, let's not, because that's depressing so to me.

SPEAKER_00 1:21

So anyway, it is closer to yours. Really?

SPEAKER_01 1:25

Well, actually, like I said, I don't want to do Jesse's 22. I don't want to do this.

SPEAKER_00 1:31

I was gonna say Savannah definitely closer in age to you, but eh, it might be closer to Jesse. Yeah, so thanks for depressing me.

SPEAKER_01 1:39

I told you I wanted to stop. Not close.

SPEAKER_00 1:42

So oh man, I how how is maybe I should ask this before we joined, and you can cut it out, I guess. But is Savannah, how is she doing?

SPEAKER_01 1:52

Oh, she's home. She wants to move to France now. Yeah, of course. She had a blast, and she's like, I really dreaded the question. Like, she's like, I know I'm gonna come home, and people are gonna say, How was France? And there's so much to talk about that I won't know what to do. So she came home and I said, How was France? She got mad at me. You need to get more specific. So, but yeah, lots of good code and pictures and learning experiences, and yeah, oh gosh, she this some of this stuff. So uh so they had an Instagram account. That's what I love about social media now. It's like all the kids every day, there were seven kids and two teachers on this trip, and the kids every day had to post something with their pictures and their stories, and so you're seeing all this beautiful architecture and artwork and statues, and and then there's my kid. It's a plant of food, it it's a beverage, it's uh pastry, a baguette, and then it's fluffy cows and a snail that she found and took to the art museum and showed the picture. You know, I was like, okay, I love this.

SPEAKER_00 3:06

Yeah, she's like, forget the art museum. Check out this snail that was on the side.

SPEAKER_01 3:12

And then took pictures of the snail, like kind of like Flat Stanley all around Paris. I was like, I love this so much. And they let the kids go to like a teen disco and then like thrift thrift shop and stuff, so it was cool. Yeah, so and how's your baby is smiling and making eye contact and gurgling and so darn cute.

SPEAKER_00 3:36

Gosh, he is just right on target, you know, because we know way too much about all those milestones. But yes, he is talking to us and eye contact, tracking objects, reaching out to touch. It's like he's to the point where he kind of wants to like hold on to the bottle, but like their hands aren't always open, you know. It's they're kind of in a fist, so it's like, you're you're not helping.

SPEAKER_01 4:05

Oh, it's so cute.

SPEAKER_00 4:07

Love that you want to help, but actually, you're not.

SPEAKER_01 4:10

It's such a fun time because it's like they finally they're finally a person, you know? Because for a while they're just like the eating, pooping, crying little cute bean, but now they're a person and they're they notice you and they give you feedback, and it's so cute. So by the way, I looked at his ears, his ears, he looks like Adam. I'm just saying.

SPEAKER_00 4:37

He is a mini version of my husband for sure. They're like little elf elf ears, like a little bit No, they look like mine. Look at my ears.

SPEAKER_01 4:46

No, they're not like yours. I mean, your ears are cute, no shade to your ears, but I think his ears are more like Adam's. Everything about him is more like Adam. Ear shade, you know what, but they say they do that in the beginning, so guys actually change diapers, and then they start to look more like you as they grow up. Oh, is that what it is? That's funny. Honestly, I read that somewhere, so it must be true. You know what? If it was on the internet, it's interrelately true.

SPEAKER_00 5:15

Oh man. Okay, well, how did we get here? It's Tuesday, it's recording. It's we told you. Did we tell you? No, no, no, we did. No, no, we did. No, no, wait, we told you that I was given a one-day notice that I was up next, I think.

SPEAKER_01 5:34

Right? And I said, no, no, no. You were like, I said, what can we expect next week, ha ha, tongue in cheek, because I knew that I didn't give you any notice. And you were like, Well, since I've had one day notice, and I said, No, it's okay, I'll do, I'll do my thing. But guess what? Amanda did her thing. Take it wang. Wa.

unknown 5:55

Yeah.

SPEAKER_01 5:56

Oh, I should put, you know what I should do is snaps for me. That's for you, girl. Yeah, girl.

SPEAKER_00 6:05

I cranked out an episode Easter Sunday. Where could you find me? Behind my laptop. But you know what? We got an episode. So I've mentioned before that I had about, I don't know, seven episodes that I kind of just started and haven't finished. So anyway, I was like, well, I'll just dig into one of those. And I truly had, I think it was eight pages done of this one. I was like, this has got to be like almost done. I'm just gonna let's just finish it, right? Let's just finish it. Yeah, yeah. So then I'm like looking into resources, and then I fell down a rabbit hole, realizing that this was a bigger, bigger situation than just one case. And so I completely switched gears and started from scratch, but anyway, it's done.

SPEAKER_01 6:52

Well, we appreciate you, and I'm I can't wait to hear it because I know it's gonna be a banger.

SPEAKER_00 6:57

Y'all. So instead of going to Colorado this time, we're gonna go to Rhode Island, and I can't wait to share this with you guys. But before we get too far into that, we need to talk about our first sponsor, who I've been thinking a lot about because my countdown of returning to work is getting smaller. Which, boo-hoo, poor me, I've been off forever. But I may need to lean into this sponsor when I go back. And this sponsor is Strong Coffee Company, who delivers premium instant blends for individuals who want convenience without compromising their health. Their signature black instant coffee, 15 grams of protein, five grams of MCTs, and 250 milligrams of adaptogens, including ashwagandha, first

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SPEAKER_00 7:48

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SPEAKER_01 8:25

I can smell that brew as you're talking about it.

SPEAKER_00 8:29

Delicious before we get into this, I just oh lordy on my.

SPEAKER_01 8:35

Did you just come from the south? Like all of a sudden there's a southern bell behind the microphone. Lauda Laude.

SPEAKER_00 8:42

Yeah, I don't know what happened to me there. Honey child. Oh yeah. Yep. I'm trying to figure out how to switch my Facebook over to this Doctor in the Truth. Doctor in the truth. Bless your cotton socks. Cause you know I got a I got a message from our friend Rich. So after he listened to the last episode, he sent me. Gosh, why didn't I look at this before we start? I thought about it so many times today. He sent me another article of a similar situation to my last episode, which is horrific that there's a similar situation. Um, if you guys recall, the last episode I covered was a case on the funeral home folks that were just dirtbag human beings. So

Listener Tip Funeral Home Horror

SPEAKER_00 9:34

he wrote to us after that one and um said that kind of like anything you can do, I can do better. Up to 200 remains of loved ones, friends and family, and half a ton of human ashes. Yes. He dropped a link for us though. It's another story, similar story from across the way. Funeral boss. This is the title of the article. Funeral boss will pay. Oh, culver's ad, get out of here, for what he did. It said a baby's mom. So I might need to just cover this one. I'm gonna see if there's enough, so I'm not gonna say too much now. But the the first sentence of this article says the mother of a stillborn baby boy who was found at an undertaker's almost two years after his funeral says the funeral director will pay for what he's horrific, horrific cheese and crackers.

SPEAKER_01 10:32

I don't know what to say. This is this is terrible. Can you I thought this was a one-off, but wow. I know. So what is wrong with people?

SPEAKER_00 10:43

Yeah, horrible. So thanks for sending. May cover yes, thanks, Rich. And as always, everyone, if you guys find anything that you'd like to send, please send it to us. I've got 9,000 resources. All facts and quotations are drawn from publicly available court records, news reports, peer-reviewed research, and official government filings. And all the references will be listed in our show notes. And again, there's so many because, like I said, I was gonna pick up where I left off on something else, and then I fell down a different spaghetti hole. So shall we just get into it?

SPEAKER_01 11:25

We should go down said spaghetti hole. I can't wait. I love me some pasta. As long as it's not creepy pasta, or yeah, I was gonna say crazy. Crazy. No, it's creepy pasta. Like the wrong kind of pasta, yeah.

SPEAKER_00 11:42

Oh yeah, okay. I can't ever remember because I'm always like throwing in spaghetti, fettuccine, like I don't know. Yeah, it's not the right kind. Okay, so trigger warnings are none. Which I said last time, but whatever. Okay. Imagine that you walk into a hospital. You're scared, maybe you're in pain, maybe you're barely conscious, you need surgery, and you put your trust in the hands of the people around you. The surgeons, the nurses, the anesthesiologists. You sign a form and you go under. Now imagine you wake up and the surgery was done on the wrong part of your body. No. This happened not once, not twice, not even three times, many times. And we're talking about a single hospital, one institution where wrong site surgeries, wrong patient procedures,

Rhode Island Hospital Pattern Emerges

SPEAKER_00 12:40

fraudulent Medicare billing, and patient deaths from preventable errors span more than a decade. Despite fines and lawsuits totaling nearly $90 million in just two of the cases, federal investigations, and a state consent agreement, the problems kept coming. This is incredible. So I c I kid you not, I was researching one of the cases, like I said, intending to cover it, right? Because it's almost done. And through the resources, I discovered that it was not an isolated error. Today we are going to be going inside Rhode Island Hospital, the largest medical center in the state of Rhode Island, and the extraordinary documented pattern of surgical errors, institutional failures, and accountability gaps that plagued it for over 10 years.

SPEAKER_01 13:33

I thought you were going to talk about like in the United States, this has happened, you know, one institution for a decade.

SPEAKER_00 13:44

One.

SPEAKER_01 13:45

Oh my god. One.

SPEAKER_00 13:50

That's why I was like, I have to just cover this hospital because while I I might still do the other case, it's already almost done, right? But when I was like, this isn't just one thing, like yeah. So before we dive in, I need to establish some context. In medicine, there's a category of mistakes so egregious, so preventable, that they have been given a specific name. They're called never events. The idea is simple. These are errors that should never happen. Wrong site surgery is one of them. It means a surgeon operates on the wrong body part, the wrong side of the body, or the wrong patient entirely. And just to be clear about the scale of this problem nationally, the Joint Commission, which is the body that accredits hospitals in the United States, estimates that wrong site surgeries happen somewhere between six and forty times per week across the country. A week? A week? They're operating on the wrong thing. So I was I was flabbergasted by that as well when I first read it. But then I was thinking, like, okay, think of how many like surgeries one single surgeon does in one single hospital a day. So I'm like, maybe that makes it a I mean, should it be happening? No. But it doesn't sound as staggering if you think about it.

SPEAKER_01 15:17

It's harder to log into your you know, your healthcare portal than it is apparently to operate on the wrong body part.

SPEAKER_00 15:28

I know. Oh my nose. This is freaking bananas. So a 2026 study published in the Patient Safety Journal analyzed 664 wrong site surgery events in Pennsylvania alone over a 10-year period, an average of more than one per week in a single state. One in four surgical malpractice crimes involve a wrong site event. These aren't statistical footnotes, these are real people. And Rhode Island Hospital, a 632-bed teaching hospital affiliated with Brown University's Alpert Medical School, racked up a record that made it one of the most scrutinized hospitals in the United States for a decade.

unknown 16:18

Okay.

SPEAKER_00 16:19

This wasn't even that long ago. Okay, so the year everything started uh unraveling. Let's hop into our time machine. Because even though I said it wasn't that long ago, some people that listen to this might think so, but not to me. It's 2007.

SPEAKER_02 16:35

Oh my goodness.

SPEAKER_00 16:36

I'm like, that was yesterday. Rhode Island Hospital is a prestigious institution. It's a level one trauma center. Brown University sends its medical students there, and patients from across New England trust it with their lives. And then in January 2007, a third-year resident fails to mark the correct location on an elderly man's head before inserting a drain. Both the doctor and the nurse later said that they hadn't been trained on how to use the required safety checklist.

SPEAKER_01 17:13

Oh, my sweet mother Mary and Joseph,

2007 Wrong Side Brain Surgeries

SPEAKER_01 17:16

are you kidding me? Okay, I'll stop.

SPEAKER_00 17:26

Well, Jenna, they didn't know how to use the required checklist. Six months later. Should have seen her face after she said, okay, I'm done. Okay, six months later. We're in July 2007. A more experienced surgeon, a man with over two decades in medicine, prepares to remove a blood clot from an 86-year-old man's skull. He didn't write which side of the head on the consent form. A nurse flagged it, but he brushed it off. He said he remembered which side. He did not remember. He drilled into the wrong side of the man's head. And when he when he realized the error, he immediately corrected course and operated on the right side, but the damage was already done. The patient died days later. State medical examiners said that they couldn't directly link the surgical error to the death, but the investigation was not over. Then, in November 2007, just four months after that, a third wrong side brain surgery at the same hospital. This time, the chief neurosurgery resident and a nurse had actually discussed the correct side ahead of time. And then, for reasons that investigators said they could not fully explain, the doctor marked and cut into the wrong side anyway, and the nurse didn't stop him.

SPEAKER_01 19:06

This is criminal.

SPEAKER_00 19:08

Mm-hmm. Exactly. Three wrong side brain surgeries in one single year. The Rhode Island Department of Health issued a $50,000 fine and a formal reprimand. Department Director David Gifford issued a statement that said, quote, we are extremely concerned about this continuing pattern. We have not seen an adequate response in the hospital system and protocols since the last order was issued, end quote. A $50,000 fine for three wrong side brain surgeries in one year. You guys. Yes, so you, you know, you might expect that three wrong side brain surgeries in a mere 12 months would be a watershed moment, a full reset of the culture at the institution. But the academic journal article published in the Journal of Medical Regulation, authored by Rhode Island physicians themselves, reviewed every wrong site surgery reported to the state's Board of Medical Licensure and Discipline between 1998 and 2008. And their conclusion? Four of them neurosurgeries. And the report reads like a grim catalog. 2002, a resident hung a CT scan facing the wrong direction and prepped a patient for a left-sided operation when the right side was intended. 2004, a catheter inserted into the wrong vessel. 2006, an emergency craniotomy on the wrong side of a trauma patient's head. 2007, two more wrong side brain operations. Which I'm like, I think I was supposed to write through there. 2008, a knee operation on the wrong knee, and the patient had to point out the mistake himself in the recovery room. Could you imagine waking up like, the fuck? You did the wrong knee. You're like, it's not April Fool's Day. What? The researchers identified a disturbing cultural pattern running through nearly every case. An over reliance by an operating surgeon on the remainder of the operating room team for patient, site, side, and procedure verification was thematic. In interviews, the notion that such verification is administrative and a nursing or anesthesia function was raised numerous times over the decade, despite repeated institutionally based education efforts. In other words, the surgeons thought it was someone else's job to double check, and everyone else thought it was the surgeon's job.

SPEAKER_01 21:42

Yeah, so it's beneath you to figure out what side of the brain you're gonna cut into.

SPEAKER_00 21:47

Yeah, you're the one with the scalpel.

SPEAKER_01 21:49

Yeah, guys.

SPEAKER_00 21:50

Yeah. The investigation into the Rhode Island surgery revealed multiple contributing factors time, pressure, ambiguity. Communication among staff and lapses in marking procedures created a perfect storm. Despite decades of policy development, including initiatives like the American Academy of Orthopedic Surgeons Sign Your Sight program in 1998, which encouraged surgeons to mark the surgical site with initials, wrong site errors continue to occur. Yes. She raises her hand. Yes, you go.

SPEAKER_01 22:25

Even as a lowly audiologist, I know that if I'm going and I have an operating room reserved for me with a patient, I'm not even doing anything invasive, but I still have to call a timeout before I start the procedure. Everyone stops what they're doing and looks at me, and I tell their name, their date of birth, their allergies, the fire hazard of the procedure, what side I'm doing, what on, and everybody has to agree before I can proceed. So if a lowly non-surgeon is required to do this, how is how is it that actual neurosurgeons who are doing invasive procedures and life life-saving procedures got away without getting this checklist done? I mean, even a pilot can't get away without getting their checklist done before they take off from the airstrip.

SPEAKER_00 23:15

Yep. So this is a sobering reminder that no system is foolproof when human judgment is involved. Hospitals and staff must do more than follow procedures. They must cultivate an environment where vigilance, questioning, and accountability are ingrained at every level. This reminds me of the medical mishap also that was sent to us about that patient advocating for themselves because the staff kept saying the procedure was going to be on the opposite side. Do you remember that one? And they were like, is this a joke?

SPEAKER_01 23:43

Like definitely.

SPEAKER_00 23:45

Yeah. Yeah. Then in October 2009, a patient went in for hand surgery on two fingers. A procedure performed on the wrong finger. Okay. And astonishingly, during the correction, the surgical team skipped the mandatory timeout protocol a second time. We're here to do a correction, guys. We're skipping timeout.

SPEAKER_01 24:08

Okay, Amanda, I think you should explain what a timeout is for those who don't know or haven't had the experience.

SPEAKER_00 24:16

Okay, so when we're all in the operating room, we before we start any doing anything, everyone's there, the whole team's there, and we call a timeout. And we all go through or someone goes through and says, This this is the patient, this is the patient's demographics that are whatever, to confirm it's the right patient, this is what we're doing. Does everyone agree? And then you go around to every person, every person that's there for whatever reason, and you say, I agree, if that is the patient that you are there for, and that's the procedure that you're there for. So that's the timeout. The only thing that has happened is the patient is asleep. So state health director Gifford, again,

What A Surgical Timeout Means

SPEAKER_00 24:58

our buddy, called that astonishing given what had already happened at the institution. And I agree, Mr. Gifford. This Gifford's on it. The state responded by fining Rhode Island Hospital $150,000 this time, which was the largest hospital fine the department had ever issued, and ordering the installation of video cameras in every single operating room. Smile, you're on camera. Right? Rhode Island became what may be the first state in the country to mandate surgical video surveillance of this kind. Timothy Babino, then the hospital's president and CEO, issued a statement saying the hospital was, quote, committed to decreasing the frequency of medical errors, including wrong site surgeries, end quote. He is now the CEO of Lifespan, the parent company that still owns Rhode Island Hospital today. Three wrong site surgeries were the headlines. But they weren't the only way Rhode Island Hospital failed its patients. In August 2009, the same year as the finger surgery incident, a man named Carl Bukamp walked into the emergency room after hitting his head. He was 44 years old. What followed was not a wrong site surgery. It was something arguably worse. A systematic failure to look, to notice, and to act. Multiple doctors examined Carl. A radiologist reviewed his CT scans and reported them as normal, but they were not. The scans showed signs of dangerous brain swelling and rising intracranial pressure. A hospitalist was notified that his condition was worsening and chose not to respond. No neuroconsult was ordered. Neurosurgeons

Neglect Case Ends In Record Verdict

SPEAKER_00 26:44

were not called to examine him in time, and the next morning, Carl unfortunately suffered a brain herniation to the point where his brain was pushing through the openings of the skull due to so much swelling. And the damage was irreversible. He fell into a coma for seven weeks and spent more than 18 months in hospitals and rehabilitation facilities before he could return home. He now requires permanent care. He has difficulty with cognition, movement, speech, and vision. He is largely confined to a wheelchair, and his wife was appointed his legal guardian. 44 years old. Rhode Island Hospital did not contest negligence at the trial. Seven doctors and two nurses were acknowledged to have been negligent. The jury was asked only to determine the financial award. In April 2015, they returned their verdict in under two hours: $15 million to Carl for pain and suffering, $5.6 million for medical expenses, and $5 million to his wife for loss of consortium. With interest, the total reached $31.5 million. And at the time, it was the largest negligence verdict ever returned in the state of Rhode Island. But Rhode Island Hospital wasn't done generating records, you guys. Just two years later, a jury would hand down an even larger verdict. And this one, too, reads like a case study in how not to practice medicine. In December 2010, Peter Safeni, 55 years old, walked into the hospital emergency room complaining of lower back pain, fatigue, and unexplained weight loss. He had been talking, er, no, he was not talking. He was talking, but he had been taking blood thinners for the past decade to manage a genetic blood clotting disorder. This is important because without this medication, his blood wouldn't clot dangerously easily. His managing physicians, Dr. John Ryan, an internalist, and Dr. Eric Wiener, Wiener, Weiner, doesn't matter, an oncologist, told him to stop taking his blood thinners so they could safely perform a colonoscopy

Blood Thinners Error And Amputation

SPEAKER_00 28:55

and rule out lymphoma. They sent him home and instructed him to return in a couple of days. So Peter came back, but at that point he had been off his medication for much more than that. It was noted 10 days. So doctors determined that he was in a hypercoagulated state, meaning that his blood was clotting dangerously. Instead of the planned procedure, they performed a bone marrow biopsy. One doctor recommended restarting the blood thinners, and that order was cancelled. He was discharged on December 22nd and told to stay off the medications until another biopsy, which was scheduled six days later, could take place. As you can imagine, he never made it to that appointment. On December 28th, he was rushed back to I obviously got sick of riding Rhode Island Hospital, I just have RIH now. He was rushed back to the hospital with life-threatening blood clots in his legs and lungs. Gangrene had already set in, and on January 7th, just three weeks after his first visit, his right leg was amputated above the knee. He spent five months in the hospital and four months in rehabilitation. He described in his lawsuit the phantom pain that never went away, the depression, the isolation, and the fear that no one would want him, the embarrassment of his disability that made him rarely leave his home. His attorney told the jury to award $20 million and they came back with $40 million. Unanimously, after two hours of deliberation with Rhode Island's 12% pre-judged judgment interest rate, the final judgment reached $61,606,570. As of September 2017, it was the largest medical malpractice verdict in Rhode Island history. And between the Carl and this case alone, juries held Rhode Island Hospital accountable for nearly $90 million in judgments in just a two-year period. Wow. Well, I'm like, also, this is where Brown University's sending their medical students.

SPEAKER_01 31:03

They can't afford this hospital, man. People need to go to it. It's a tiny state. Go somewhere else. Like, I mean Right? Throw a rack, you'll be somewhere else. Yeah, guys, let's reroute.

SPEAKER_00 31:15

Yeah. Before we go into that, a quick side note. Um, if you heard this, I didn't think I was maybe making noise, but if you heard that, I'm patting my dog's belly. Oh, that's a cute sound. So sorry. And and now it's time for a chart note. Yikes. Some tight vocal folds there. Okay. Welcome to the chart note segment where we learn about what's happening in medicine and healthcare. Okie dokie, let's talk about something that sounds straight out of science fiction, but is very, very real. Imagine if doctors could send tiny particles into your bloodstream, so small that you'd never feel them, and those particles could actually hunt down dangerous plaque in your arteries and help remove it. That's exactly what researchers are working on right now. Scientists at an Australian Research Institute have developed specially I'm sorry. It was like my tongue wasn't moving how it was supposed to. Specially

Chart Note Nanoparticles And Plaque

SPEAKER_00 32:25

engineered nanoparticles, basically microscopic delivery systems that can target one of the biggest causes of heart attacks, plaque buildup in the arteries. Now, quick refresher. When we talk about plaque, we're not talking about the plaque on your teeth, even though I know we talk about dentistry a lot on the pod. We are talking about fatty, cholesterol-filled deposits that build up along the walls of your arteries. So over time, these deposits harden and narrow the arteries, making it harder for blood to flow through. And if one of these plaques ruptures, well, that can trigger a heart attack or a stroke. What makes this even more dangerous is plaque isn't just sitting there quietly, it's actually part of an ongoing battle inside of your body, a cycle of inflammation and cholesterol buildup that keeps feeding itself. And that's where these nanoparticles come in. Once injected into the bloodstream, these particles are designed to be taken up by immune cells that are already hanging out on the inside of the inflamed plaques. So instead of just floating around randomly, they go exactly where the problem is. And then they get to work. The nanoparticles help pull cholesterol out of the plaque almost like a microscopic vacuum. And they also reduce inflammation in the area, which is a huge deal because inflammation is what makes plaque unstable and more likely to rupture. Even better, the cholesterol they remove doesn't just stay there, it gets transported back to the liver where the body can actually process and eliminate it. So instead of just slowing the disease down, this approach could potentially reverse some of the damage. In early studies, we're talking preclinical, not yet in humans, researchers saw not only a reduction in inflammation, but actually shrinking of the plaques themselves. And here's another really interesting piece is these nanoparticles can also double as an imaging tool. That means that doctors could potentially use them to find dangerous plaque earlier before a patient ever has symptoms. So think about that for a second. A single technology that could both detect and treat heart disease at the same time. And now to be clear, again, this is a very early stage research situation. We're not to the point where you can walk in your doctor's office and be like, I want the little nanoparticles. There are still years and years of testing, safety trials, and regulatory hurdles ahead. But the concept is incredibly promising because right now most treatments for heart disease focus on managing risk by lowering your cholesterol, controlling your blood pressure, and maybe placing stents if things get bad enough. So this is different, and this is going to directly go right to the source of the problem and trying to clean it up from the inside out. And if it works in humans the way it's working in early studies, it could completely change how we treat one of the leading causes of death worldwide. So yeah, tiny particles floating through your bloodstream, quietly cleaning out your arteries. Not maybe science fiction anymore. Wow. Wow. Wrong side surgeries, record malpractice verdicts. You might think that this was enough scandal for one institution, but no no no no. There's another layer. One that involved not negligence but deliberate fraud. So in February 2012, Rhode Island Hospital entered into a civil settlement with the federal government. The investigation was conducted jointly by the United States Attorney's Office for the District of Rhode Island, the Office of Inspector General for the Department of Health and Human Services, and the Federal Bureau of Investigation. What they found was this. Between January 2004 and December 2009, so a six-year period. Wow. Wait, four, nine, eight, seven, six, five-year period. Sorry. I was like, I'm not good at math, but that's not right. Rhode Island Hospital had billed Medicare and Medicaid for overnight hospital stays for approximately 260

Medicare Billing Fraud Settlement

SPEAKER_00 36:25

patients who underwent a procedure called stereotactic radiosurgery, which is also known as gamma knife treatment. Gamma knife is a form of targeted radiation therapy typically used to treat brain tumors. The issue was that these overnight stays were medically unnecessary. The patients did not need to be admitted overnight, but the hospital billed for it anyway. Federal investigators determined that those claims were false representations, that the hospital had knowingly submitted fraudulent billing to Medicare and Medicaid, and the settlement required Rhode Island Hospital to reimburse the federal health care programs for approximately $2.6 million for the fraudulent claims and to pay an additional $2.7 million in double and triple damages under the False Claims Act. Their total payout was $3.5 million to the federal government for a scheme that ran five years and totaled 260 patients. I'm like, how does this place have any money? And what's particularly striking about the settlement is its timing because the hospital was paying out the fraud settlement while simultaneously defending against the lawsuits for the patients who had been wrongly operated on and misdiagnosed. And while being monitored under state enforcement orders, in addition to, as we'll touch on in a moment, still generating new surgical errors. So now we're in June of 2018. The article that sparked this episode to for me to cover this episode, actually, is the hospital as a whole and not just one of the many, apparently, cases, was published on June 11, 2018 by Go Local Providence, which is a local investigative news outlet. It documented the most recent enforcement action against Rhode Island Hospital by the Rhode Island Department of Health, which was a formal consent agreement requiring the hospital to spend $1 million on new training and safety protocols. The consent agreement detailed four specific incidents that had occurred in just a seven-week window, February through March

2018 Consent Order New Failures

SPEAKER_00 38:29

of 2018. Oh my gosh. This is not funny. It's just, it just seems like you can't make this up. Yeah. So February 21st, a patient underwent ACT angiography of the brain and neck that was intended for a different patient. February 26th, a patient was not correctly identified and received an angiogram that belonged to someone else. March 12th, a patient underwent a surgical. They went under underwent a spine procedure. Cervical vertebrae C6, when intended vertebrae to be operated on was C7. Oops. March 16th, a patient received a mammogram of the right breast that was intended for another patient. So four separate incidents, four separate patients, all within seven weeks. The consent agreement stated that Rhode Island Hospital had, quote, failed to implement and sustained processes and systems to provide care and services in accordance with its written policies and procedures pertaining to patient identification and verification, verification of procedure site inside, and providers' orders for diagnostic services, end quote. The very basic thing. So they had policies, they had the procedures, they had been through all this before, and yet the errors kept happening. And the gap wasn't the rule book, you guys. It was the culture. Rhode Island Health Director Nicole Alexander Scott, in her statement accompanying the consent agreement, said, quote, whenever preventable errors occur in hospital settings, it is essential that we scrutinize those errors carefully and that facilities make the system changes needed to ensure that they do not occur again, end quote. A $1 million training requirement after a decade of fines, lawsuits, consent decrees, federal fraud settlements, and video cameras in the operating rooms. A $1 million training requirement.

SPEAKER_01 40:29

I was like, how's this place even open anymore? Yeah. Wow. Yeah.

SPEAKER_00 40:34

Yeah. So we've walked through a decade plus of documented failure. The question any reasonable Alley Cat is asking now is what? Why? And how does this happen? How does a prestigious academic medical center, one with access to the best training, the best resources, the best oversight mechanisms in American healthcare, end up here? Part of the answer is in that academic journal that I cited earlier. The Rhode Island physicians who studied their own state's wrong site surgery history identified several recurring risk factors. Over reliance on other team members to catch errors, a cultural belief among surgeons that site verification is administrative work beneath them essentially, an insufficient near-missreporting,

Culture Failures And Normalized Risk

SPEAKER_00 41:21

and a reluctance to speak up even when something looks wrong. Yeah. Okay. So Johns Hopkins Medical Center had estimated that more than 250,000 deaths per year in the U.S. are attributed to medical error, making it the third leasing leading cause of death behind heart disease and cancer and ahead of respiratory disease. The CDC puts respiratory disease at roughly 150,000 deaths per year. 150,000 deaths per year for respiratory disease, and medical error surpasses that. That is crazy. And yet there's no entry for medical error in the national mortality statistics. There's no ICD 10 code for it. Hospitals self-report many adverse events. Reporting is not uniform across states. The Joint Commission receives reports of 8 to 12 wrong site surgeries per month nationally, but researchers believe the actual rate is far higher since voluntary reporting captures only a fraction of events, and I fullheartedly agree with that, unfortunately. What Rhode Island Hospital represents is what happens when the gap between written policy and actual practice is never truly closed. They had the checklists and the consent forms. They had mandatory timeouts before surgery procedures, and they had video cameras installed. They had federal monitors, and the errors continued. Not because the tools were wrong, but because the cultural infrastructure to consistently use the tools never fully materialized. There's a concept in patient safety called normalization of deviance, a term coined by sociologist Diane Vaughn in her analysis of the Challenger Space Shuttle disaster. It describes how organizations over time can come to accept substandard practice as normal because nothing catastrophic has happened yet. The warning signs get rationalized and the shortcuts become routine. Apply that lens to Rhode Island Hospital and the story becomes uncomfortably familiar. Each wrong site surgery triggered a fine, a statement of concern, a new protocol, but the culture, the underlying belief that this was someone else's job, that the checklist was a formality, that it wouldn't happen again. The culture was far harder to legislate away. So who's accountable? Here's something we're sitting in, because in every one of the wrong site surgery cases, the physicians involved were rarely, if ever, stripped of their medical licenses. The 2008 Academic Review noted that in most cases, the Board of Medical entered into consent orders, required administrative fees, sometimes as low as $500, or issued reprimands. In some cases, physicians were not sanctioned at all. The institution paid the fines and the civil settlements. They haired consultants, installed cameras, and revised their checklists. The patients and families received jury verdicts when they chose to sue and when they had the

Accountability Without A Witch Hunt

SPEAKER_00 44:17

resources to do so. But the individuals who, for example, made the incision on the wrong side of the frickin' skull continued to practice medicine. And I want to be very clear here that I'm not calling for a punitive witch hunt. Research consistently shows that a name and blame culture in medicine actually makes things worse because it discourages honest reporting of near misses, which are some of the most powerful tools available for preventing future harm. But accountability is not the same thing as punishment. And from the outside, looking at a decade, a decade of same failures at the same institution, it is difficult to argue that accountability in any meaningful sense was fully achieved. The parents, spouses, and children of the people like Carl, who now live out his days in a wheelchair requiring permanent care because he's unable to feed himself, are left to carry the weight of the consequences that were entirely preventable. Rhode Island Hospital still operates today and is still one of the premier trauma centers in New England. It still houses cutting-edge cancer research programs and receives tens of millions of dollars in NIH grants. And in fairness, the hospital has implemented changes over the years. But the record we've covered today is well-documented public record. And the story of Rhode Island Hospital over that decade is not the story of one rogue surgeon or one bad actor. It's the story of a system that generated preventable harm repeatedly and the gap between institutional intention and institutional reality, a gap that patients paid for with their bodies, and in at least one case, their lives.

SPEAKER_01 46:02

And if you don't feel safe to speak up, if if you're a nurse, a scrub nurse, and you're like, wait, I thought this was supposed to be the left here, and you're wrong, and you risk the wrath of the surgeon. I mean, but also this was stuff that was identified and worked out like decades ago that was like a huge problem all across the US. Where was Rhode Island? Were their heads in the sand? Were they not paying attention? Like, we've been here. And yet here they are less than 10 years ago, screwing it up because what? Rhode Island is like superior to everybody else? They don't they don't need checks and balances? Like I don't I I just don't get it how this little pocket of healthcare can get away with this for a decade. Not to beat a dead horse, but what the hell? Why do they get to continue to receive tens of millions of dollars in NIH grants? Maybe what's happened so far to encourage them to reverse their culture and work on safety, like everybody else in the United States has had to do. Maybe they don't need to receive tens of millions of dollars in NIH grants if they aren't up to stuff. And it sounds like, yeah, okay, yay, they've made some changes. Honestly, part of me wants to say too little, too late. Come on, guys. I mean marking the site, making sure you have time out, making sure people are rewarded and encouraged and feel safe to be able to speak up. I mean, this is basic, basic stuff that we learned again with the pilots because it's like the co-pilot. I I don't even remember the whole story, but there was a co-pilot that didn't speak up because you know he didn't want to tell a senior pilot that something was not checked or not working, the plane crashed, everybody died. People learned. We started checklists. The pilots do it, we should do it in the operating room. So I don't know. Are we feeling confident that things got turned around eventually?

SPEAKER_00 48:01

I mean, I want to say yeah, because how are we still sending Ivy League med students there? But also 2018 was the last thing I reported, and so that was not long ago.

SPEAKER_01 48:16

Would you send your mom there? No. Would I send my mom there? No. You guys need to prove yourselves. So it's beyond like keeping up to snuff with what the rest of the country is doing, but it's like you have no excuse. You have all the resources and all the referrals and all the prestige, and this is unconscionable.

SPEAKER_00 48:38

So yeah, just get the slap on the hand.

SPEAKER_01 48:40

Yeah, wild bananas. Thank you for bringing this up. Yeah. It was a great case. Thank you.

SPEAKER_00 48:48

You're welcome. Well done. Thank you. Thank you. Thank you. So before we head to medical mishap, you know we got to talk about sponsor number two. And for that, we are going to be talking about elevating your hair care routine with Yark Plant-Based Hair Care, the ultimate fusion of nature and luxury. Their organic vegan shampoos, conditioners, and mousses are meticulously crafted to feed your hair with a potent blend of vitamins, minerals, and essential oils. Free from alcohol, parabens, and sulfates, the products deliver a nourishing experience that your hair honestly deserves. Embrace the power of clean beauty with yark, where every drop is thoughtfully curated to enhance your hair's natural beauty while respecting this beautiful planet.

Sponsor Break Yark Hair Care

SPEAKER_00 49:34

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SPEAKER_01 49:54

I know I do. I want that. Is it time for our medical mix chat? Yeah, girl. There's no subject line on this one, but it says hello, lovely ladies, which I mean, I like to think that's me and you.

SPEAKER_00 50:09

I I would say, I mean, Ray Ray is usually with me. She a girl. She can be in the club.

SPEAKER_01 50:15

All of us lovely and even Whiffle. Wiffy bit. Which I like to think. Oh, she hasn't proven it forensically, but I feel like she's a girl. Okay. Hello, lovely ladies. I've been wanting to write in, but never felt that I had a mishap worthy of being read. Okay, first of all.

SPEAKER_00 50:32

You guys, we hear that all the time. Just send it.

SPEAKER_01 50:36

Oh my gosh, you are so worthy. We love that you're listening. We want to share your stories. Are you kidding me?

Listener Chart Note Silent Hypoxia

unknown 50:43

Yeah.

SPEAKER_00 50:44

Do you think my husband with his scrotum staple to his leg, that he thought that's a story worthy of sharing? Probably not. And I I understand that the the that's a very pretty severe medical mishap, but it doesn't have to be that severe.

SPEAKER_01 51:02

Maybe that's what we need to say. It doesn't need to be that severe or that painful. Like we just want to hear from you guys.

SPEAKER_00 51:09

Maybe we shouldn't have shared Adam's story because it has really raised the bar for what people think that we're trying to find here.

SPEAKER_01 51:18

No, listen, let's take Adam on a scale of like hit mishaps from like, eh, nothing happened to you. Why are you moaning about it? Which is zero to 10. Like, ah, you know, you're in a lot of pain and something really horrible happened to Adam, which is like your turn was staple to your leg. 15. So we accept and plenty from zero to ten. You don't have to be a 15.

SPEAKER_00 51:45

Let us not forget that the point of adding the medical mishap at the end from our dear friend Rich. His idea is to lighten the mood after talking about shit bags and horrible things. So just send it in.

SPEAKER_01 52:02

Send it in. Let us have the people at your expense. We're good for it. Yeah, for sure. You can't tell me you haven't carved a pumpkin and like stabbed yourself accidentally, or something happened.

SPEAKER_00 52:14

So or you're trying to cut an avocado open and you tried to get the pit out and you didn't stab yourself with a knife. You know you've done it. 27 people listening right now. Do you have done that? Yes, exactly. We want to hear about it.

SPEAKER_01 52:25

So anyway, anyways. This listener says, Hello, lovely ladies. I've been wanting to write in, but never felt I had a mishap worthy of being read and didn't feel the right to steal someone else's story without consent. Okay, listen, you just yeah, you're too hard on yourself. We talked about this. Okay. So I have decided I would send in my own chart note to assist in educating the public. Is that okay? Yes. It's okay. Yes. Well, we're doing it, and I suppose you either choose to read it or not. We're choosing to read it. The fat of this information is in your hands. Did I mention that I resonate with your guys' ADHD comments? My name is Cindy, and I've worked as a pulmonologist for nearly 30 years. So let's get into it, as you'd say. Okay, Cindy. There's a phenomenon in medicine that sounds almost impossible at first. Patients who are critically low on oxygen but don't feel like they can't breathe. Scary. It's often referred to as silent hypoxia. Oh gosh. And it became widely recognized during the early days of the COVID-19 pandemic. Clinicians were seeing patients walk into the hospital talking in full sentences, saying they felt a little off while their oxygen levels were dangerously low. This is horrible. Normally, when oxygen drops, the body sends out clear distress signals like shortness of breath, rapid breathing, that panic feeling that forces you to stop and gasp. But in some cases, especially with certain lung conditions, that alarm system doesn't trigger the way we expect. Instead of oxygen levels being the main driver of that air hunger feeling, the body actually responds more strongly to rising carbon dioxide levels. And in silent hypoxia, carbon dioxide can remain relatively normal, even while oxygen is falling. Oh my gosh. Oh my. So the brain doesn't get the same urgent signal that something's wrong. At the same time, diseases like COVID can affect how oxygen moves from the lungs into the bloodstream without immediately impacting how easily the lungs expand. So patients don't feel that classic tightness or struggle, even as their oxygen saturation drops into dangerous territory. So the result is a disconnect between how a patient feels and what their body is actually experiencing. The takeaway here is simple but important. How someone feels isn't always a reliable indicator of how sick they are. It's why tools like pulse oximeters became so important, not because they replace symptoms, but because sometimes they catch what symptoms don't. And it's a reminder that in pulmonary medicine, some of the most clinically significant conditions can present with surprisingly subtle symptoms. The absence of obvious distress doesn't always reflect the severity of underlying hypoxemia, which is why objective data and careful assessment are so critical. Also, thank you both for creating this podcast. As someone who works in healthcare and has always had an interest in true crime, it's such a unique and engaging blend of both worlds. I always look forward to new episodes, especially hearing what's emerging in the chart notes segment. And for the record, I too sing like an alley cat. So stay safe and stay suspicious of hypoxia. Cheers, Cindy.

SPEAKER_00 56:11

Cindy. Thank you, Cindy. I know I feel like I feel breathless just like from watching your reaction here. I have like secondary, like just go in. Huh. Okay. Well, well, Jenna, what can we expect to hear next week?

SPEAKER_01 56:29

Part one of the Lucy Letby nurse episode where she is accused of killing multiple babies. And there's a lot to this case, and most listeners have probably heard something about it. Two pada. But I'm hoping to bring a little bit of genesequa, a little extra, and maybe some new evidence that hasn't been universally covered in the media. So there's that. So it's wild. It may turn out to be a three pata.

SPEAKER_00 57:02

Sounds good. We'll be here for all two, three,

Next Week Tease And Closing

SPEAKER_00 57:06

or whatever, however many parts it is. So don't miss a beat, people. Subscribe or follow Doctoring the Truth wherever you enjoy your podcasts for stories that shock, intrigue, and educate. Because trust, after all, is a delicate thing. You can text us directly on our website at doctoringthe truth at buzzsprout.com. Email us all of your stories, ideas, and comments at Doctoringthe Truth at Gmail. And be sure to follow us on Instagram at Doctoring the Truth Podcast and Facebook at Doctoring the Truth. We are also on TikTok at Doctoring the Truth and ed odd pod. Don't forget to download, rate, and review so we can be sure to bring you more content next week. Until then, stay safe and stay suspicious. Oh my gosh.

unknown 57:54

Oh my god.

SPEAKER_00 57:57

No, I can't hear anything. Well, bye. Well three, two, one, five.