HospitalInspections.org

Based on interview and documentation review it was determined the Hospital failed to ensure changes were made to the process of educating OR nursing staff after the data collected had identified an opportunity for improvement in one of one applicable medical record reviewed.


Findings include:

Review of 7/14/10 OR Staff Meeting minutes indicated the updated surgical count policy was reviewed with the OR nursing staff. Review of the attendance at the meeting indicated the Circulating Nurse, the Scrub Nurse and the Scrub Technician were had not attend the meeting.

The Coordinator for Patient Safety & Quality was interviewed in person on 12/20/10, at 2:00 PM. The Coordinator for Patient Safety & Quality said he/she had reviewed July, 14, 2010 OR Staff Meeting attendance record and found the Circulating Nurse, the Scrub Nurse and the Scrub Technician had not attended the meeting and therefore had not received information related to the revised count policy. He/She said there was no documentation to indicated the information related to the revisions was ever reviewed with the three staff members.

Review of the Hospital internal investigation did not indicate the absence of the Circulating Nurse, the Scrub Nurse and the Scrub Technician at the 7/14/10 OR Staff Meeting, was acknowledged or that the process for educating OR nursing staff members was changed to ensure all nursing staff received the needed information/education.

Based on interview and documentation review it was determined the Hospital failed to ensure assigned nursing staff had the appropriate education in one of one applicable medical record reviewed.

Refer to Tag # A-276