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Based on record review and interview it was evident that the facility failed to provide anesthesia services in a consistently safe manner.

These findings were identified at the Wakefield Division.

Findings include:

1.Review of MR #2 on 10/ 15 /12 found that a patient in the OR received in error an unknown quantity of Sefroflurane anesthetic gas via face mask. Review of the anesthesia record finds no reference to this event.

The QA summary for this event did not determine who applied the face mask to the patient, how long the patient was receiving the gas, and whether the delivery system in place protects from this type of error.

At interview with the director of anesthesiology on 10/ 15 /12 it was reported that a patient should be intubated prior to the induction of this gas and that it was not possible to find how this error could have occurred when all staff deny involvement.


2. Review of MR # 3 on 10/ 15 /12 found that a patient in the OR was administered Heparin 20,000 units IV by the anesthesia resident instead of the prescribed dose of 3000 units. This was noticed immediately and Protamine 50 mg was administered during the course of the surgery.

At interview with the anesthesia director on 10/ 15 /12 it was reported that it was too early to determine how this event occurred other than that the resident assumed that the vial was a single dose one.

The patient required a return to the OR the same day for evacuation of a large hematoma at the site of a newly created brachiobasilic fistula.

The facility failed to put a plan in place to address this issue and prevent it from re-occuring.

Based on record review and interview it was evident that the facility failed to ensure that an accurate anesthesia record was maintained for a patient who received an anesthetic gas in error.


These findings were identified at the Wakefield Division.

Findings include:

Review of MR #2 on 10/16/12 found that the patient received Sefloflurane gas in error over an indeterminate period of time and sustained hypotension which was treated with a blood transfusion. Reference to this incident was found only in the surgeon's notes.

Review of the anesthesia records found no reference to this event.

At interview with the anesthesia director on 10/ 17 /12 it was discussed that although this event occurred there is no documentation of this event in the anesthesia record.