The state health department has cited North Shore University Hospital for 14 violations after two neurosurgeons failed to operate on a sedated patient lying on an operating table.
"When a hospital schedules a patient for surgery, the patient has the right to expect that the surgeon is there and patient will get the appropriate care," said Health Department spokeswoman Claudia Hutton.
On April 10, Jennifer Ronca, 32, of Tunkhannock, Pa., underwent the first part of a two-part brain surgery at the Manhasset hospital. But the neurosurgeon scheduled to do the second operation that day, Dr. Paolo Bolognese, was out of town.
The hospital's chief of neurosurgery, Dr. Thomas Milhorat, refused to step in to do the surgery. A week later the hospital suspended both surgeons for three weeks. Milhorat retired soon after. Bolognese remains on staff.
According to the health department report released last Friday, Bolognese had made plans to travel but the only flight available was on the morning of Ronca's surgery. The night before, Bolognese e-mailed another surgeon about doing the surgery but did not call him or get an answer to his e-mail, the state said.
When Ronca awoke, she was told that Bolognese had had a family emergency.
"What is astounding to me is that an institution like North Shore, which I consider provides exemplary care, could allow something like this to happen," said Ronca's attorney, Mark L. Bodner of Manhattan.
North Shore spokesman Terry Lynam said the hospital "has thoroughly investigated and addressed" the "breakdown in communication" that caused the incident. Lynam said the report contains "a number of factual findings and conclusions with which we disagree." The hospital has until Oct. 2 to give the state a plan of correction and faces fines, up to $2,000 for each infraction.
The violations also include:
The orthopedic surgeon who did the first surgery but then left the operating room before a neurosurgeon arrived.
The anesthesiologist sedated the patient before the arrival of the neurosurgeon.
Milhorat dictated the notes on the first operation "although he was not present in the operating room." Milhorat could not be reached for comment.
The operating team did not call a "time out" before beginning the second operation. A "time out" ensures the right procedure is being done on the right patient and right part of the body.
The hospital failed to follow up on 27 "near miss site verification errors" in 2008 - 16 of them for "neurosurgical errors." These are errors, in this case caught before surgery, that could lead to surgical or patient-identification mistakes. Some of these can be major, such as operating on the wrong body part, or relatively minor, such as not putting an allergy band on an allergic patient.
Lynam said the hospital had followed up with all the cases.