HospitalInspections.org

Based on medical record review, policy review and interview, the laboratory staff has not ensured proper patient identification and specimen collection in 2 of 20 patients (Patient #2 and #19) having blood obtained for laboratory testing. This has the potential to result in an adverse patient event.

Findings include:

Review of policy "Laboratory Identification of Patients and Specimens" last revised 03/14 revealed for inpatient identification, staff are to use the Soft ID PC barcode scanner, visually inspect the patient's ID bracelet, verbally communicate by asking the patient to state their full name and date of birth and use the Zebra Bar Code computer labels printed prior to bedside sampling.

Medical record review for Patient #2 dated 05/25/17 revealed an addendum at 07:00 PM indicating the baby is very jaundiced appearing, T. bilirubin at 06:00 AM was 6.5 (6.0-10.0). Will repeat now, if near treatment level, will start phototherapy tonight to not delay discharge. Mother aware. At 07:08 PM the physician was made aware of baby's bilirubin of 13.7 (repeat result). A new order was received for triple phototherapy to begin tonight and a repeat bilirubin at 06:00 AM as well as a direct neonatal bilirubin.

Review of laboratory bilirubin results for Patient #2 revealed on 05/25/17 at 06:19 AM result of 6.5 mg/dl, reference range (6.0-10.0) and at 07:31 PM a result of 13.7. On 05/26/17 at 06:50 AM a result of 12.5 and direct bilirubin of 0.3 (0.0-0.3).

Review of laboratory bilirubin results for Patient #19 revealed on 05/25/17 at 06:00 AM result of 11.3 mg/dl (6.0-10.0) and at 06:47 PM a result of 6.2 and direct bilirubin 0.2 (0.0-0.3).

Interview on 08/08/17 at 09:00 AM with Staff (A), Chief Nursing Officer (CNO) revealed that the maternity/infant nurse noted Patient # 2 to be jaundiced despite normal bilirubin result on 05/25/17. The physician was notified and the bilirubin was repeated with an elevated result requiring phototherapy treatment. It was determined during facility investigation, that the phlebotomist mislabeled the specimen on the initial bilirubin testing with another infant's label (Patient #19) causing the wrong infant to receive phototherapy. The parents of both infants were notified of error and phototherapy was started on Patient #2. Initial blood work was canceled and re-drawn on both Patient #2 and #19.

Interview on 08/08/17 at 10:50 AM with Staff (D), Phlebotomist, revealed that she obtained initial bloodwork on Patient #2 and #19 on 05/25/17 but did not use the Motorola scanner and label printer when performing identification of both patients. She did check the crib identification with the ankle band. Staff (D) had pre-printed labels on four infants that morning and set the labels on the counter in the lab draw area across from the newborn nursery. Infants are identified in the newborn nursery by phlebotomist and moved across the hallway to the lab draw area to obtain specimens. Staff (D) did not know she had placed the wrong label on the blood obtained from Patient #2 until she was notified of error. Staff (D) is aware of the facility policy for patient identification but did not follow this policy on that morning.
Interview on 08/08/17 at 01:30 PM with Staff (J), Maternity RN revealed Patient # 2 and Patient #19 were in newborn nursery on 05/25/17. Patient #19 was under the lights but Patient # 2 was the infant that appeared jaundiced. Staff (J) immediately notified the pediatrician and bilirubin was re-ordered with elevated result. Phototherapy was immediately started on Patient #2.

Interview on 08/08/17 at 02:00 PM with Staff (A), CNO, verified these findings.

Based on medical record review, document review and interview, the facility did not develop and/or implement a policy to ensure the safety of the patient during cesarean section deliveries in surgical services.

Findings include:

Review of Nursing Labor and Delivery documentation for Patient # 1 dated 05/23/17 revealed at 11:39 AM an Internal Scalp Electrode was applied by physician and internal fetal monitoring tracing continued into operating room for cesarean section.

Review Nursing Intraoperative documentation for Patient # 1 dated 05/23/17 at 04:11 PM revealed the initial surgical count, 2nd count and final count all indicated that the instrument count, sharps & miscellaneous count and sponge count were correct. However, there is no evidence that the Internal Fetal Scalp Electrode (FSE) was included in the surgical counts.

Interview on 8/8/17 at 12:00 PM with Staff (A), Chief Nursing Officer (CNO) and Staff (F), Registered Nurse (RN)revealed Patient #1 (mother) and Patient #2 (infant) were discharged from the hospital on 05/26/17. Patient #1 reported that on 06/05/17, she passed the internal fetal scalp electrode vaginally while going to the bathroom and took it to her physician follow-up appointment who reported this event. Staff (F), RN, indicated that there is a procedure for Fetal Scalp Electrode (FSE) Placement/Insertion but it does not address removal. Electrodes have never been included on the surgical count record.

Interview on 08/08/17 at 01:00 PM with Staff (A), CNO, verified these findings.