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BROWN UNIVERSITY HEALTH SAINT ANNE'S HOSPITAL
No Description Available
Tag No.: A0287
Based on interviews and documentation review the Hospital investigation failed to identify that the Hospital's Policy and practice did not identify the process for ensuring the site marking was visible after draping (if applicable).
Findings included:
Observation of a procedure performed in the Pain Management Center during the survey determined that the site for the intended procedure was properly marked and was visible after draping. The time-out was performed with all members present and actively participating, including the patient (Patient #10) however, the time-out did not include members observing the site marking to ensure it was visible after draping.
Signage posted in the suite regarding the time-out process indicated that it was not the practice to include observation of the site marking to ensure it was visible after draping.
Nurse #1 was interviewed on 4/28/11 at 12:05 P.M. Nurse #1 said observation of the procedure site after draping to ensure the site marking was visible did not occur during the time-out process.
Review of the Hospital's Policy/Procedure titled Universal Protocol indicated that the site marking had to be visible after draping (if applicable) but did not indicate who was responsible or what step(s) were taken to ensure that occurred.
The Hospital conducted an investigation following a wrong side procedure. The Investigation did not identify that the Hospital's Policy and practice did not identify how it was ensured that site marking was visible after draping (if applicable).
PATIENT SAFETY
Tag No.: A0286
Based on interviews and documentation review the Hospital investigation failed to identify that the Hospital's Policy and practice did not identify the process for ensuring the site marking was visible after draping (if applicable).
Findings included:
Observation of a procedure performed in the Pain Management Center during the survey determined that the site for the intended procedure was properly marked and was visible after draping. The time-out was performed with all members present and actively participating, including the patient (Patient #10) however, the time-out did not include members observing the site marking to ensure it was visible after draping.
Signage posted in the suite regarding the time-out process indicated that it was not the practice to include observation of the site marking to ensure it was visible after draping.
Nurse #1 was interviewed on 4/28/11 at 12:05 P.M. Nurse #1 said observation of the procedure site after draping to ensure the site marking was visible did not occur during the time-out process.
Review of the Hospital's Policy/Procedure titled Universal Protocol indicated that the site marking had to be visible after draping (if applicable) but did not indicate who was responsible or what step(s) were taken to ensure that occurred.
The Hospital conducted an investigation following a wrong side procedure. The Investigation did not identify that the Hospital's Policy and practice did not identify how it was ensured that site marking was visible after draping (if applicable).