HospitalInspections.org

Based on clinical record review and interview, it was determined the Facility failed to provide a safe environment in that the staff failed to verify the placement of an IV (intravenous) catheter prior to administration of a contrast agent, failed to ensure the IV catheter was the correct size for injection of the contrast agent, and failed to perform an incident report after extravasation of the contrast agent for one of one (#1) patient reviewed for IV contrast agent administration. The failed practice did not ensure the IV catheter's placement and size were correct and failing to file an incident report did not ensure the Facility placed corrective actions in place to keep the incident from reoccurring. The failed practice affected Patient #1 and had the potential to affect all patients receiving a contrast agent. The findings follow:

A. Review of Patient #1's clinical record on 10/18/16 revealed the following:
1) A CT scan of the pelvis with IV contrast was ordered on 03/21/16 at 1738.
2) Nursing documentation revealed Patient #1 had a 22 gauge IV placed in her right hand on 03/21/16 at 1759 with blood return noted.
3) Registered Nurse's noted dated 03/21/16 at 1815 revealed, "Site Observation: Edematous; Red (pt. (patient) hand edematous and pink after infiltrating while receiving IV contrast. Warm dressing placed over site.)"
4) Radiology Technician's note dated 03/21/16 at 1827 revealed, "...Comment: right hand injected with IV about 60 ml (milliliters) contrast created a bolus on top of the hand. Warm packs applied. ER (Emergency Room) nurse started new IV line in left arm."
5) Peripheral IV documentation revealed a 20 gauge IV was placed in Patient #1's left forearm on 03/21/16 at 1818.

B. Review of the policy "Intravascular Contrast Administration for Computed Tomography and Diagnostic X-ray" on 10/18/16 revealed the following:
"D. Intravenous Access: If deviation from the below protocol is thought necessary, the technologist should contact the supervising Radiologist or Licensed Independent Practitioner/Physician.
2. Lines that can be used for Power Injection:
Hickman
Triple Lumen
Power PICC (Peripherally Inserted Central Catheter)
Single Lumen Cordis Sheath in neck or groin
20 g (gauge) Antecubital
22 g or 24 g may be used if necessary for venous access.
F. Contrast Extravasation Guidelines
2. All extravasation events should be documented in the medical record and incident report...".

C. The findings of A and B were confirmed in an interview with the Clinical Coordinator for Radiology on 10/18/16 at 1305. When asked if the Radiology Technician was supposed to verify the IV site was patent and able to use prior to administration of the contrast agent, she stated yes. She stated the "Computed Tomography Contrast Administration and Lab" form was to be used.

D. Review of Patient #1's "Computed Tomography Contrast Administration and Lab" form, the Clinical Coordinator for Radiology stated the Radiology Technician should have placed an "x" or a checkmark in front of "Administer 0.9% Sodium Chloride Injection USP (United Stated Pharmacopoeia) Intravenously ____ ml (see injection rate below)" to indicate the verification was performed. She stated the Radiology Technician should have placed a numerical value in the blank line to indicate the amount of Sodium Chloride injected. In an interview with the Clinical Coordinator for Radiology on 10/18/16 at 1305, she confirmed there was no evidence the Radiology Technician verified the placement of the IV site prior to administration of the contrast agent.

E. In an interview with the Clinical Coordinator for Radiology on 10/18/16 at 1305, when asked why the 22 g IV in the patient's right hand was used as apposed to placing a 20 gauge IV in the antecubital, she confirmed there was no evidence as to why a 20 gauge IV wasn't placed in the antecubital or why the second 20 gauge IV was placed in the patient's left arm instead of the antecubital.

F. A request was made for the incident report following the extravasation of the contrast. In an interview with the Quality Facility on 10/18/16 at 1520, she confirmed there was no evidence an incident report was filed.