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Based on observation, staff interview, medical record review, and review of documentation, it was determined the hospital failed to provide evidence of systemic and continuous actions to measure improvement of the communication expectations between Anesthesiologist and the Certified Registered Nurse Anesthetists after identifying two cases where the (CRNA) failed to timely notify the anesthesiologist with a change in a patient's condition and failed to ensure the supervising anesthesiologist for the Certified Registered Nurse Anesthetist (CRNA) in the magnetic resonance imaging (MRI) area was identified in the medical record. (A01001) This cumulative effect of these systemic practices resulted in the hospital's inability to ensure anesthesia services is operating safely and effectively.

Based on medical record review, documentation review and staff interview it was determined the hospital failed to provide evidence of systemic and continuous actions to measure improvement of the communication expectations between Anesthesiologist and the Certified Registered Nurse Anesthetists (CRNA) following identification and review of two patient deaths post operatively where there was a delay of communication from the (CRNA) to the anesthesiologist. (Patient's #2 and #3) In addition, the hospital failed to document the supervising anesthesiologist of the Certified Registered Nurse Anesthetist (CRNA) for Patient #1. Six medical records were reviewed with anesthesia administered in the operating rooms, MRI, or OB unit. A total of ten medical records were reviewed. The active patient census was 219.


Findings include:

1. The medical record review for Patient #2 revealed a history of bladder carcinoma who underwent a hand assisted laparoscopic right radical nephroureterectomy on 01/15/16. The medical record confirmed a (CRNA) was assigned to the case with a supervising anesthesiologist.

An interview was conducted on 02/15/17 at 4:15 PM with the anesthesiologist supervising the case. The patient began to exhibit changes in the end tidal C02 and the (CRNA) requested the anesthesiologist be called. When the anesthesiologist arrived the change in vital signs was noted and the case was suspended. The blood bank was called for blood products and CPR was performed, however, the patient expired.

The 01/15/16 case was reviewed by the peer review committee on 02/10/16 with a notification letter to the (CRNA) of the findings. Per the letter it was noted that nearly 30 minutes of time elapsed between negatively trending vital and physician notification.


2. The medical record review for Patient #3 revealed on 11/28/16 the patient underwent a cystoscopy and a transurethral resection of the prostate. The medical record confirmed a (CRNA) and a supervising anesthesiologist. The anesthesia was started at 8:34 AM and the surgery started at 8:50 AM. The anesthesia record confirmed at 9:15 AM sinus bradycardia with bigeminy and a low blood pressure treated with epinephrine. Further, the note revealed the supervising anesthesiologist was in the operating room suite at this time and updated with the EKG change and blood pressure changes being treated with vasopressors. At 9:28 AM supraventricular tachycardia was treated with 20 mg of Esomolol. At 9:34 AM surgery was stopped and at 9:40 AM the supervising anesthesiologist was notified again of a complete heart block on the EKG. Emergency cardiac medications were administered, an intraoperative consult to cardiology was made for a third degree heart block/myocardial ischemia, and a call for the defibrillator. Cardiology responded to the operating room prior to cardiac arrest. At 9:56 AM the anesthesiologist placed an arterial line, the second anesthesiologist placed a transesophageal echocardiography. CPR was initiated at 10:00 AM due to cardiac arrest. The patient expired in the intensive care unit following a second code blue.

An interview was conducted with the anesthesiologist on this case on 02/15/17 at 4:15 PM who stated this was an extremely difficult case as the patient had extensive unknown cardiac issues. The surgical case went to peer review on 02/08/16 as the patient did expire post operatively. The committee recommended (CRNA) escalation in a more timely manner based on changes in the patient's condition despite medical therapy.


Interview with Staff A, Chief of Anesthesia, on 02/16/17 at approximately 3:30 PM, communication occurs daily in the morning anesthesia huddle of when to notify the anesthesiologist. Upon request the hospital failed to provide evidence of systemic and continuous actions to measure improvement of the communication expectations between Anesthesiologist and the Certified Registered Nurse Anesthetists. A meeting is scheduled for 03/08/17 and is being presented by the Chief of Anesthesia with regard to escalation of care/communication expectations.


3. Review of the medical record for Patient #1 revealed the patient reported to the emergency department due to shortness of breath, neck pain and a headache. The patient was treated and discharged from the emergency department and returned on 10/13/16 with an altered mental status/confusion. An MRI was attempted once and was unable to be completed, the second attempted MRI required anesthesia assistance/intubation. The (CRNA) completed the pre-anesthesia assessment with no previous anesthetic complications noted. The medical record listed Penicillin (anaphylaxis) as the only drug allergy.

Per (CRNA) documentation the patient was administered sedative medications and within one minute following intubation the (CRNA) noted a possible allergic reaction with facial, neck, and body swelling with rigidity. A code blue was called and an emergency tracheostomy was performed.

The medical record failed to confirm the supervising anesthesiologist of the (CRNA) assigned to the case. Staff E, Anesthesiologist, confirmed this finding on 02/15/17 at 4:33 PM.

Staff D, Vice President of Clinical Quality Management, stated in an interview regarding this lack of evidence on 02/15/17 at 3:45 PM the staff working the MRI area completes documentation on paper and not in the electronic medical record.

A schedule was provided of the anesthesiologist who was supervising the (CRNA), however, this was not noted in the medical record.