HospitalInspections.org

Based on documentation review, it was determined the Hospital had not (yet) fully implemented the Corrective Action Plan associated with its Internal Investigation of Patient #1's SRE/retained surgical sponge.

Findings included:

A review of the Hospital Internal Investigation related to Patient #1's SRE/retained surgical sponge revealed it identified that:
> Prolonged and complex surgery such as Patient #1's first surgery (the hysterectomy and a right salpingo-oophorectomy) is rarely performed in an L&D OR.
> Surgical wounds are almost never left open and packed in the L&D ORs.
> Twenty lap pads are generally utilized during an uncomplicated c-section and 140 were utilized during Patient #1's c-section.
> The Women & Infants Services policy/procedure regarding the counting of sponges, sharps and instruments did not include policy/procedure for sponges that are intentionally left in patients leaving the OR.
> The number of lap pads packed in Patient #1's open wound was not documented by L&D OR staff.
> Documentation regarding sponges intentionally left in patients was not being consistently completed in accordance with policy/procedure in the Perioperative Service.
> Radiopaque material seen projecting over Patient #1's left upper quadrant in the abdominal x-ray performed following her second surgery (exploratory laparotomy for bleeding) did not look like a sponge (because of the way it was positioned) and was not immediately recognized as a sponge.
> Surgeon #2 closed Patient #1's abdomen before obtaining the abdominal x-ray because the operative counts (for Surgery #2) were correct, the surgery had been emergent, and she wanted to get into the abdomen, address any bleeding, close the abdomen, and return Patient #1 to the ICU as quickly as possible. Surgeon #2 also knew Patient #1 would be returning to the OR for a cystoscopy and an evaluation of the ureters.

A review of the Corrective Action Plan associated with the Hospital Internal Investigation revealed it called for:
> A review (and possible revision) of the policy/procedure regarding sponges intentionally left in patients leaving the OR within the Perioperative Services "Counting - Sponges, Sharps, Instruments" Policy/Procedure.
> The incorporation of the (reviewed or revised) Perioperative Services policy/procedure regarding sponges intentionally left in patients leaving the OR into the Women & Infants Services "Counting - Sponges, Sharps, Instruments" Policy/Procedure.
> Education of the Perioperative and Women & Infant Services staff regarding the policy/procedure to be utilized when sponges are intentionally left in patients leaving the OR.
> Development of a Quality Monitoring Plan related to staff compliance with the new, current and/or revised policy/procedure regarding sponges intentionally left in patients leaving the OR.
> A Root Cause Analysis.

A review of the Corrective Action Plan implementation revealed:
> A RCA Team had been identified and a meeting was scheduled for 2/3/11.

Based on documentation review it was determined the Hospital had not (yet) developed and implemented quality monitoring related to the Corrective Action Plan associated with its Internal Investigation of Patient #1's SRE/retained surgical sponge.

Findings included:

Please see Tag A 288 for information regarding the Corrective Action and Quality Monitoring Plans associated with the Hospital Internal Investigation of Patient #1's SRE/retained surgical sponge.

Because the Corrective Action Plan was not (yet) fully implemented, the Quality Monitoring Plan related to staff compliance with the new, current and/or revised policy/procedure regarding sponges intentionally left in patients leaving the OR was not developed and implemented.