HospitalInspections.org

Based on document review and interview, it was determined that in 1 of 10 (Pt #1) clinical records reviewed of patients requiring surgery, the Hospital failed to ensure the surgeon that obtained the informed surgical consent was the same surgeon that performed the procedure.

Findings include:

1. Hospital policy entitled, "Informed Consent," (approval 4/12/12) required, "Procedure...C. The provider who intends to perform a procedure...discusses the risks, benefits and alternatives to treatment with the patient..."

2. Pt #1 was a 51 year old female admitted on 7/2/14 with a chief complaint of "Uterine fibroids and pelvic pain." Pt #1 was scheduled to undergo a total abdominal hysterectomy, possible bilateral salpingo-oopherectomy (removal of the ovaries and fallopian tubes) on 7/2/14.

Pt #1's clinical record contained a "Consent for Surgery " dated 7/2/14 at 6:50 AM that included, "1. I authorize the performance upon (Pt #1) the following procedure(s): Total Abdominal Hysterectomy, Bilateral Salpingectomies (removal of the fallopian tubes). 2. I authorize (Pt #1's attending physician MD #1) (and whomever is designated as the doctor's assistant) to perform the above mentioned operation ..."

Pt #1's Anesthesia pre-procedure evaluation dictated on 7/2/14 at 8:00 AM included, "Surgeon(s) and role: MD #1 - primary and MD #2 (associate of MD #1)." However Pt #1's operative report dated 7/2/14 at 11:22 AM indicated, "Surgeon : MD #2; First assistant MD #1..."

Pt #1's clinical record contained an operative report dated 7/2/14 at 11:22 AM that included, "Surgeon : MD #2; First assistant MD #1..."

3. The Hospital ' s surgical schedule dated 7/2/14 was reviewed on 3/23/16 at approximately 1:00 PM. The schedule included Pt #1, the procedure performed, and listed MD #1 as the surgeon.

4. On 3/24/16 at approximately 10:45 AM Pt #1's attending physician (MD #1) was interviewed. MD #1 stated, "(MD #2) is the main partner in the group and when I operate with him I ask if he wants to do the procedure. I did not know that (MD #2) name was not on the consent."

5. On 3/24/16 at approximately 11:15 AM the surgeon listed as the one that performed Pt #1's surgery (MD #2) was interviewed. MD #2 stated, "This was (MD #1's) patient. Normally all of our names are placed on the consent and mine should have been."

6. The Administrative Director of Population Management (case management/accreditation) stated during an interview on 3/24/16 at approximately 2:00 PM that the consent should have had the surgeon's name performing the surgery on it.