Altman, Lawrence K. "Sloan-Kettering Fined $12,000 for Surgery on Wrong Side of Woman's

 

Altman, Lawrence K. "Sloan-Kettering Fined $12,000 for Surgery on Wrong Side of Woman's
Brain," New York Times, 9 March 1996, . 27.

Memorial Sloan-Kettering Cancer Center in New York City has been fined $12,000, the
maximum allowed by state law, in a case in which a surgeon operated on the wrong side of a
patient's brain, officials of the State Health Department and the center said yesterday.

Under the terms of an agreement, the center, one of the most prestigious cancer hospitals in the
country, may end up paying only $6,000 because the state said it would suspend half the fine
"provided that the hospital is not found in violation of any state hospital code standards for at
least one year."

Health-care experts said that the amount of a fine was less important to a hospital than the
publicity.

Memorial Sloan-Kettering also agreed that it had violated standards of care in this case, which
involved Dr. Ehud Arbit, then the center's chief of neurosurgery. On May 26, 1995, he operated
on the wrong side of the brain of Rajeswari Ayyappan, who had traveled from India to the
hospital for removal of a tumor. Dr. Arbit reported that he had confused Mrs. Ayyappan with
another patient from Indian whose records had been sent to him for review.

In June, the cancer center took steps to guard against such errors. One was to institute a plan that
requires an operating surgeon and a senior nurse to document a review of patient records before
surgery.

Memorial Sloan-Kettering "cooperated fully in our investigation," Dr. Barbara A. DeBuono, the
State Health Commissioner, said yesterday.

Last November, Dr, DeBuono issued a scathing report saying that "systematic deficiencies" at
the hospital had led Dr. Arbit to make the error and said the state intended to fine the hospital
$16,000, $2,000 for each of eight citations.

The state has dropped two citations. One concerned a patient consent form for the operation. In
November, the state said its investigators had found no identifiable patient signature on the form.
However, the cancer center later produced documents signed by Mrs. Ayyappan that indicated
her signature was on the consent form, Frances E. Tarlton, a spokeswoman for the Health
Department, said yesterday.

The second dismissed citation concerned the center's plans for quality assurance. Ms. Tarlton
said her department had determined that the hospital;s actions were acceptable.

Avice A. Meehan, a spokeswoman for cancer center, said: "Memorial Sloan-Kettering Cancer
Center remains committed to delivering the highest possible quality of care to our patients. We
have dismissed the neurosurgeon involved in the case and remain vigilant in our efforts to insure
that such a breach does not occur again."
The cancer center rejected Dr. Arbit's appeals for reinstatement, Mr. Meehan said. David
Hoffman, a lawyer for Dr. Arbit, said that he could not comment because of civil litigation
undertaken by the Ayyappan family against Dr. Arbit, who now practices at Staten Island
University Medical Center. State officials said that they were prohibited by law from
commenting on any such case. Mr. Hoffman said he had no comment.

Ms. Meehan said she did not know the status of Mrs. Ayyappan.