HospitalInspections.org

Based on observation and interview, the CAH (Critical Access Hospital) failed to assure anesthesia carts remained locked when not in use and drugs used by anesthesia staff are disposed of after completion of each patient anesthesia case. Findings include:

Per observation of the anesthesia cart in Operating Room #2 on 4/23/13 at 11:30 AM, drawer #2, which contained multiple anesthetic and cardiac drugs used during administration of anesthesia, was found unlocked. Per interview on 4/23/13 at 11:43 AM, the CRNA (Certified Registered Nurse Anesthetist) who last used the cart on 4/23/13 stated s/he had completed a surgical case at approximately 9:00 AM and acknowledged the failure to lock the cart. The CRNA also confirmed the predrawn syringe of the drug Ephedrine 25 mg found sitting on top of the anesthesia cart should have been disposed of by the CRNA at the completion of the anesthesia case.

Per interview the Chief Operating Officer (COO) and the Chief of Anesthesia on the afternoon of 4/23/13 both confirmed the Pyxis Anesthesia System has an automatic locking system which would have locked drawer #2 within 90 minutes after use, despite the fact that the CRNA had neglected to secure the cart. The exception to this would be that the CRNA had not completely closed drawer #2 after use, preventing the automatic locking of the cart to occur. Although, the Chief of Anesthesia and COO also confirmed an alarm would sound when the Pyxis system could not perform a locking function, staff may not have heard the Pyxis alarm 90 minutes after the completion of the last surgical case, due to no perioperative staff being in the vicinity of Operating Room #2 who could have responded to the alarm. However, they both confirmed the CRNA should assure the anesthesia cart is consistently locked when not in use or if left unlocked the cart was within direct supervision of authorized staff. In addition, the drug left on the anesthesia cart by CRNA should have been disposed of by the CRNA at the completion of the surgical case.