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MONTEFIORE MEDICAL CENTER
PRE-ANESTHESIA EVALUATION
Tag No.: A1003
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.