HospitalInspections.org

Based on review of hospital policies and procedures and on staff interviews, it was determined the hospital failed to evaluate corrective action plans implemented for areas identified for improvement related to investigation of adverse events.

Findings include:

The hospital provided a policy and procedure on the subject of Conducting a Root Cause Analysis The policy had an effective date of "9/98" and included: "...A root cause analysis is conducted in response to an adverse sentinel event...When Mt. Graham Regional Medical Center detects or suspects a sentinel event, it shall promptly initiate an intensive assessment to reduce variation and prvent the event from recurring in the future...The goal is to identify changes, which could be made in systems and process - either through redesign or development of new systems or process that would reduce the risk of such events occurring in the future, implement those changes, and evaluate results...."

The hospital provided documentation of their analysis of an incident that occurred in February in their labor and delivery unit. An epidural catheter had been placed and the clip at the end of the catheter became dislodged and contaminated. An emergency cesarean section had to be performed under general anesthesia and there were concerns about the placement of the endotracheal tube. After the successfuly delivery of the infant the patient was taken to her room for postpartum recovery. The patient had significant bleeding which was not accurately measured and reported by the postpartum RN. The patient required 4 units of packed red blood cells. The patient's temperature increased to 102 degrees Fahrenheit four and one-half hours after surgery.

The hospital's analysis included "Areas identified for improvement" and "Plan of Action." The Director of Quality Improvement stated during an interview on 11/24/2014 that the plans of action were implemented, however, there was no documentation that the interventions were evaluated to ensure they were effective and sustainable in order to prevent similar events from occurring in the future.