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Based on interview and documentation review, it was determined the Hospital had not (yet) finished its Investigation related to Patient #1's wrong site procedure.

Findings included:

Documentation indicated Patient #1; a patient who underwent a right total knee replacement and was scheduled to have a postoperative right lower extremity nerve block, was incorrectly administered a postoperative left lower extremity nerve block. Documentation also indicated: Patient #1 was informed of the error; the left lower extremity nerve block was discontinued; a right lower extremity nerve block was administered and; there was no untoward patient outcome.

A review of Anesthesia, Operating Room (OR) and PACU Incident Reports completed during the time period of 7/15-10/15/10 revealed a Report regarding Patient #1's wrong site procedure, and documentation indicated a Hospital Internal Investigation to include a Root Cause Analysis was underway.

A review of the Hospital Internal Investigation To-Date revealed it had determined: the physicians who administered the left lower extremity nerve block to Patient #1 (Attending Anesthesiologist #2 and Anesthesia Resident #2) failed to follow Hospital policies/procedures related to surgical/procedural site marking and verification of the surgical/procedural site during "Time Out"; the Physician's failure to follow the Time Out/Universal Protocol Policy/Procedure was an isolated practice variance and; Attending Anesthesiologist #1 failed to complete Patient #1's Consent for Anesthesia in accordance with policy/procedure. The review also determined a Corrective Action Plan related to the Hospital Internal Investigation To-Date was developed.

A review of the Corrective Action Plan To-Date revealed it called for the counseling and re-education of Attending Anesthesiologist #2 and Anesthesia Resident #2 regarding the Time Out/Universal Protocol Policy/Procedure and the re-education all Department of Anesthesia physicians regarding specifying laterality on Consents for Anesthesia (when applicable) and the Time Out/Universal Protocol Policy/Procedure. The review also determined that as of 11/1/10; the Corrective Action Plan To-Date was implemented/completed.

The Vice Chair of Anesthesiology was interviewed in person at 10:25 AM on 11/4/10. He/she said the Department of Anesthesia was considering requiring preoperative procedure site marking for postoperative nerve blocks and recommending that pre-procedure Time Outs be conducted by at least 2 departments/disciplines, and a RCA Meeting was scheduled for 11/9/10.

Continued review of the 7/15-10/15/10 Anesthesia, OR and PACU Incident Reports did not reveal Reports related to other wrong site procedures.

A review of medical records related to 9 other patients who underwent invasive procedures involving laterality did not reveal deficient practices related to Consents for Anesthesia and/or the Time Out/Universal Protocol Policy/Procedure.

Based on interviews and documentation review, it was determined the Hospital had not (yet) completed its Internal Investigation related to Patient #1's wrong site procedure and therefore had not fully developed and implemented a Corrective Action Plan.

Findings included:

Please see Tag A 287 for information regarding Patient #1, his/her wrong site procedure and the Hospital's Internal Investigation To-Date.

The Hospital Internal Investigation was underway, but not (yet) completed and a Corrective Action Plan was therefore not fully developed and implemented.

Based on interviews and documentation review, it was determined the Hospital had not (yet) completed its Internal Investigation related to Patient #1's wrong site procedure and therefore had not fully developed and implemented a Corrective Action Plan and Quality Monitoring Plan.

Findings included:

Please see Tag A 287 for information regarding Patient #1, his/her wrong site procedure and the Hospital's Internal Investigation To-Date.

The Hospital Internal Investigation was underway, but not (yet) completed, and Corrective Action and Quality Monitoring Plan were therefore not fully developed/implemented.

Documentation indicated the Hospital routinely monitors the Time Out/Universal Protocol process and documentation of the process.