HospitalInspections.org

Based on review of documentation and interviews, it was determined that the Hospital failed to ensure there was an established policy for the removal/surgical count of grids and strips.

Findings include:

Review of Patient #1's medical record indicated that grids and strips were temporarily placed on Patient #1's brain to pinpoint the area where his/her seizure activity originated. Three days after the grids and strips were placed, Patient #1 returned to the OR for removal of the grids and strips. The surgical count was documented as correct. Two days after the procedure to remove all of the grids and strips, a computed tomography scan (imaging test) identified that one electrode had been left in.

The Attending Neurosurgeon (AN) was interviewed on 10/17/11 at 11:20 AM with the Director of Risk Management present. The AN said that he was not aware that the Hospital was not utilizing the same counting procedure for the grids/strips that he was familiar with to ensure all of the pieces were accounted for, until the incident involving Patient #1 was reviewed.

The Director of Risk Management said the Hospital had implemented a change in the grids & strip count procedure and were now in the process of writing policies to reflect this change.

At the time of the Survey, the policies the addressing grids & strip removal/surgical count were still not completed.