HospitalInspections.org
Bringing transparency to federal inspections
MILFORD REGIONAL MEDICAL CENTER
QUALITY IMPROVEMENT ACTIVITIES
Tag No.: A0283
Based on record review and staff interview, the Hospital failed to ensure that the corrective action plan was fully implemented in a timely manner.
Findings include:
1.) The Hospital reported a Serious Reportable Incident (SRE) on 10/16/12. The report indicated that on 3/22/12 Patient (Pt.) #1 had a post-operative surgical wound drain removed by a physician assistant (PA). However, unknown to the PA, part of the drain remained in Pt. #1's left knee when the drain was removed. The PA did not realized that a small piece of the drain remained in the surgical wound. Pt. #1 was seen at his/her Orthopedic Surgeon's office on 4/19/12 when an x-ray showed a retained fragment of the surgical wound drain. The Attending Orthopedic Surgeon informed Pt. #1 of the surgical error. The Attending Orthopedic Surgeon advised Pt. #1 of the risks and benefits of proceeding with the surgical removal of the remained drain fragment, or waiting to see how Pt. #1 progressed before proceeding with an additional surgery.
2.) The Hospital conducted a Root Cause Analysis and identified the Attending Orthopedic Surgeon failed to report to the Hospital's Risk Management Department that a small piece of the drain remained in the surgical wound. The Hospital's Action Plan was not completely implemented because the medical staff had not received the re-education that an event or clinical situation must be reported to the Risk Management Department or the Vice President for Medical Affairs when the incident is identified.
QUALITY IMPROVEMENT ACTIVITIES
Tag No.: A0283
Based on record review and staff interview, the Hospital failed to ensure that the corrective action plan was fully implemented in a timely manner.
Findings include:
1.) The Hospital reported a Serious Reportable Incident (SRE) on 10/16/12. The report indicated that on 3/22/12 Patient (Pt.) #1 had a post-operative surgical wound drain removed by a physician assistant (PA). However, unknown to the PA, part of the drain remained in Pt. #1's left knee when the drain was removed. The PA did not realized that a small piece of the drain remained in the surgical wound. Pt. #1 was seen at his/her Orthopedic Surgeon's office on 4/19/12 when an x-ray showed a retained fragment of the surgical wound drain. The Attending Orthopedic Surgeon informed Pt. #1 of the surgical error. The Attending Orthopedic Surgeon advised Pt. #1 of the risks and benefits of proceeding with the surgical removal of the remained drain fragment, or waiting to see how Pt. #1 progressed before proceeding with an additional surgery.
2.) The Hospital conducted a Root Cause Analysis and identified the Attending Orthopedic Surgeon failed to report to the Hospital's Risk Management Department that a small piece of the drain remained in the surgical wound. The Hospital's Action Plan was not completely implemented because the medical staff had not received the re-education that an event or clinical situation must be reported to the Risk Management Department or the Vice President for Medical Affairs when the incident is identified.