HospitalInspections.org

Based on document review and interviews, the facility failed to provide sufficient evidence that the hospital's quality program implemented a thorough corrective action plan that would identify and reduce future potential medical errors.

The document titled, Improvement Action Plan (a plan in response to Patient #1's missed Lidocaine allergy on 06/21/18 that resulted in Patient #1's anaphylactic reaction and decline in condition), stated that re-education of anesthesiology staff was completed by 07/26/18.

The document titled Anesthesia Lectures for Eye and Ear Infirmary (a presentation that discussed Patient #1's missed Lidocaine allergy on 06/21/18 that resulted in Patient #1's anaphylactic reaction and decline in condition), dated 07/26/18, displayed 21 of 44 missing attestations. The Facility could not provide documentation that all other anesthesia team members were made aware of the 06/21/18 Lidocaine allergy event and were educated on corrective actions.

The Surveyor interviewed Physician #1 at 9:55 A.M. on 08/29/18. Physician #1 said she was unaware if the department had conducted any changes or corrective action after the 06/21/18 Lidocaine allergy event.

Based on record review and interviews the Hospital failed to provide, for one (Patient #1) of ten sampled patients, a thorough and complete pre-anesthesia evaluation. Patient #1's drug allergy of Lidocaine was not appreciated and led to Patient #1 suffering an allergic reaction, a decline in condition and an emergent transfer to a tertiary care facility.

The medical record section titled Allergy Review History for Patient #1, dated 06/12/18, indicated that Patient #1 had an allergy to anesthetics - Amide Type (Lidocaine is an amide type) with a comment of bradycardia (low heart rate).

The document titled Anesthesia Postprocedure Evaluation, dated 06/21/18, indicated that Patient #1 experienced anesthesia complications and required multiple pressors (medications to help increase blood pressure). The surgery was aborted and Patient #1 was taken to a tertiary care facility's emergency department.

The Surveyor interviewed Physician #1 at 9:55 A.M. on 08/29/18. Physician #1 acknowledged that she (Physician #1) did not fully review and assess Patient #1's drug allergy history. Physician #1 acknowledged that the lidocaine allergy did not come up on verbal handoff with Physician #2 (the physician who was in the operating room and administered the lidocaine to Patient #1).