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Based on observation, interview and record review, the facility failed to ensure the necessary equipment was available prior to putting the patient under anesthesia for 1 (Patient#1) of 32 patients scheduled for surgery, potentially resulting in less than optimal outcomes for all surgical patients served by the facility.

See specific tag A-0941

Based on observation, interview and record review, the facility failed to ensure the necessary equipment was available prior to putting the patient under anesthesia for 1 (Patient#1) of 32 patients scheduled for surgery, potentially resulting in less than optimal outcomes for all surgical patients served by the facility.

Findings:

On 04/05/22 at 1110 during medical record review, it was determined that Patient (Pt) #1 was a 27-year-old male with a history right shoulder dislocations and right shoulder pain. The medical record showed no prior history of Medical or Surgical diagnoses. Pt #1 presented to the facility on 02/23/22 for a previously scheduled right shoulder arthroscopy with " Bankart+ replissage " (repair of torn tendon and filling a ' divot ' on the humoral head). Pt #1 ' s Surgical Consent was observed in the medical record.

On 04/05/22 at 1015, during review of Incident Report document titled "Current Summary" dated 02/23/22, p.1 of 9, and written by multiple authors, revealed "We did not have EZ Y WRAP product in order to wrap the hand and arm appropriately in order to perform the surgery. We were notified by CSS (Central Sterile Services) on our pick sheet (list/order of needed surgical supplies) labeled with a question mark, and no one followed through to see what and why we needed this product. Dr. (Staff V) attempted to put patient in correct lateral position, but Dr. (Staff V) was not comfortable with doing the procedure without the correct positioning product." The patient was inducted under anesthesia with nerve blocks but whose surgery was ultimately canceled due vital surgical equipment not being available for the surgeons use.

On 04/05/22 at 1025, tours of this acute care hospitals' 3 Tower Perioperative unit and 4 South Medical/Surgical Unit were conducted with Staff H and Staff J. Observations, interviews, and record reviews were conducted with staff and patients. No concerns were identified.

On 04/05/22 at 1100, Director of OR (Staff H) was interviewed and queried, 'How are supplies ordered for surgery? Staff H stated, "There is a pick-sheet on top of the surgical cart. This one (Pt #1's) arrived and the OR staff saw it had a question mark on it. They checked the stock and found a piece missing, so the surgery was canceled. They tried to use an alternative method of positioning, but that didn't work, so it was canceled. The patient didn't get charged." Staff H was queried regarding the procedural checks before surgery, Staff H stated, "there are three checks; first, we have an 'OR huddle' each day, to look at today's surgery and the next three days. This is myself, OR staff, and managers from Materials management and Sterile Services. Second, is the 'forecast' report, which is a report of missing items from Materials Management. Thirdly, is the person 'pulling' the case cart (filling cart). A yellow sheet (listing missing items) should have been issued and been on the cart." An example 'pick-sheet' for this particular surgical case was requested from Staff H and was provided shortly after.

At 04/05/22 at 1115 during medical record review of "Orthopedic Surgery Update Note" dated 02/23/22 and authored by Surgery Resident (Staff W), revealed Attending Surgeon "Dr. (Staff V) was then notified that proper equipment for patient positioning was not available once patient was already intubated and in the OR. ... Planned right shoulder surgical intervention canceled due to lack of proper positioning equipment."
On 04/0522@ 1120, document review of 'Procedure Summary' dated 02/23/22, listed 'Events' timeline with Anesthesiologist (Staff I) entering a note at 1200, stating "Surgeon unable to complete case due to equipment issue. Cancellation occurred after induction, and blocks completed."


On 04/05/22 at 1245, during interview with Director of Quality (Staff T), Staff T was queried when the last Surgical Quality Meeting was held? Staff T stated, "I think they met last month (March). I'd have to check." Meeting minutes were requested from the last meeting held, and Staff T returned shortly after and stated, "We don't yet have the minutes from the meeting, but I can get you the slides."

On 04/05/22 at 1300, during review of Policy #7489753 (revised 01/13/2020) titled "Operating Room/Endoscopy Scheduling (facility name)", paragraph (3), subsection 1, (E) revealed, "The operating room personnel are responsible for scheduling cases, taking into consideration time, personnel and equipment requirements. Every effort will be made to accommodate physicians' requests, if possible."

On 04/05/22 at 1340, a telephone interview was again conducted with Director of OR (Staff H). Staff H explained that a 'pick-sheet' list was utilized to assemble surgical supplies prior to surgery. The Sterile Processing department would gather the supplies into a 'cart' which would be delivered to surgery. Staff H stated, "EZ Y Wrap holds the arm in place at a 90 degree angle. Sterile Processing 'pull's the cart' (filling it) with disposable and sterile products. If a part is missing, the person 'pulling the cart' would call Materials Management for the missing piece. CSS got called away and forgot to call Materials Management (about the missing EZ wrap). The OR team pulled the cart into the OR, found a piece was missing and called the doc." Staff H was next queried regarding the 'pick-sheet' example provided. Staff H was informed that no item called "EZ y Wrap" was listed on the pick sheet document. Staff H stated, "Are you sure? Do you want me to spell it for you?" The pick sheet was reviewed by Accreditation manager (Staff E) and Staff E confirmed no such listing at 1346. Staff H stated, "Maybe they grabbed the wrong list." Staff H arrived moments later to review the list and stated, "its right here", pointing to the first item listed, titled "Arthrowand ASHA4250 90 deg."(sic). Staff H stated, "that's the product right there, its not listed as 'EZ wrap'. Its not something we use frequently." Staff H was queried if the pick list product title was a factor in its omission? Staff H neither confirmed nor denied but replied, "We just don't use that product that much anymore."

On 04/05/22 at 1400, during review of document titled, "MSQC P4P 2022 Measures-Abdominal Hernia" (not dated) revealed printed 'power-point slides. The printed slides were reviewed and contained no information on reporting Incidents or variances in the delivery of Surgical services.

On 04/06/22 at 0930, a tour of CSS was conducted with Staff C, H, J, and X. The Manager of CSS (Staff X) described the process of 'pulling carts' and related the new processes implemented from the incident investigation. Staff X pointed to a wall mounted document holder, stating "this would be the location where 'Yellow sheets' (carbon copy of pick-list) would now be stored." The missing item in question, (EZ Y WRAP) was requested, and was observed 'in-stock' on a nearby supply shelf.

On, 04/06/22 at 1101, an interview was conducted with Director of OR, Staff H. Staff H was again queried if the patient was inducted (anesthetized) and intubated prior to noting the missing supply item. Staff H, stated, "I did not review the chart, the managers did. I went by what was written in the RL (RL Solutions, Incident reporting system)." Staff H was next questioned if she had participated in writing the 'RL'. Staff H pointed to sections of the report and stated, "yes, here, and here." Staff H was then queried if the discovery of missing supplies, after induction and intubation, changes the seriousness of the error. Staff H, stated, "Definitely intubation changes the seriousness."

On 04/06/22 at 1230, an interview was conducted with Chief Medical Officer (Staff Q). Staff Q was queried if the surgical supplies should have been confirmed prior to Pt #1 being inducted and intubated. Staff Q, stated, "From what I was told, the decision to cancel surgery was made before the patient was anesthetized."

Pt. #1 was anesthetized and intubated prior to the facility ensuring the necessary supplies were available for the surgery. Policy #7489753 states that OR personnel are responsible for boarding cases, considering personal, timing and equipment needs.