HospitalInspections.org

Based on the review of medical records, the review of hospital policy, and interviews with hospital staff, it was determined that in one of ten medical records, medical record # 1, the hospital failed to ensure the patient's right to receive care in a safe setting. Findings:

Review of Medical record # 1 determined the following.

Medical Record # 1 contained a "Patient Informed Consent" that listed the name of the procedure as "Eye Muscle Surgery, & removal of lesions from neck." Additionally under "Mark the following as applicable: one or both eyes" Under that was a check box that was checked for "Right-sided procedure" but a checkbox that was not checked for "Left-side procedure." The Consent was signed by the mother of the minor child on 4/6/2011 at 2:50 PM.

On 4/28/2011 at 9:00 AM, Interviewee A produced a form titled "Emanuel Hospital Legacy Health System Surgical Services Reservation" that listed a procedure to occur on 4/13/2011 at 9:30 that under the procedure (s) box stated:
"1. Probable Right Inferior Oblique weakening
2. Possible Left Inferior Rectus recession"
The document named Patient #1 as the recipient of the procedure.

On 4/28/2011 at 9:00 AM, Interviewee A relayed that although there may be a specific problem with a single eye, surgical correction may involve surgery on both eyes to maintain the patient's binocular vision. Interviewee A also noted that the surgeon, C1, includes the eventuality of surgery on both eyes on the informed consent form for that reason and when scheduling surgery so as to have sufficient supplies available and in the ready.

Interviewee A, on 4/29/2011 at 8:16 AM, was interviewed on the preliminary findings of a hospital root cause analysis meeting on 4/27/2011. This meeting was held in response to a wrong-site surgery incident at the hospital. Interviewee A reported that in a discussion with Patient #1's mother prior to surgery, C1 indicated that the surgery would be confined to the patient's right eye. The 04/13/2011 "Operative /Procedure Notes" contained in Patient Record #1 stated:"Preoperatively, PARQ with (the patient's) mother was conducted, including a discussion of surgery on the right eye alone versus surgery on both eyes at the same time, though I (C1) was leaning to confine surgery to the right eye at this time."

There was an experienced eye surgery scrub nurse attending the surgery, Staff member #1, and a second nurse learning the specialty of eye surgery, Staff member #4. There were surgical setups on both sides of the patient. Both eyes were prepped.

Interviewee A reported that the universal protocol had occurred prior to the 4/13/2011 operation on Patient # 1 as was documented in that medical record. Staff within the operating room during that surgery recalled that during the universal protocol the right eye was identified as the surgical site. Despite this C1 set down on the patient's left and proceeded to perform surgery on the left eye.

The 04/13/2011 "Operative /Procedure Notes" contained in Patient Record #1 stated: "Attention was directed to the left eye after the adhesive skin drape was inadvertently placed over the opened left eye." The record contains a description of the surgery performed on the left eye. Other staff members did not identify that C1 was working on the left eye rather than the right eye identified as the surgical site. The 04/13/2011 "Operative /Procedure Notes" contained in Patient Record #1 stated: "It was at this point that it was recognized that in fact the right inferior oblique muscle had been the intended muscle for myectomy" C1 proceeded to the right eye and performed the operation on that eye. C1 removed a number of lesions from the patient's neck and chest. C1 had a conversation with the patient's family after the operation.

The 04/13/2011 "Operative /Procedure Notes" contained in Patient Record #1 stated: "Complications: Inadvertent left inferior oblique myectomy."