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Based on review of the Hospital's Internal Investigation and interviews with the Podiatry Resident, Director of Risk Management and Regulatory Affairs, the Chairman of Quality and Safety and the Attending Podiatrist regarding a wrong site surgical block (left foot) performed in the Operating Room on 12/2/11 on Patient #1, it was determined that the Hospital's investigation failed to identity that medical students provided direct care to Pt #1 which may have also contributed to the anesthetic block being administered to the left foot, instead of the correct foot (right) and the Hospital had not implemented Action Item #3 in the corrective action plan.

Findings include:

Background Information:

The Hospital reported that a wrong site anesthetic block occurred, was investigated and reported on 12/9/11. The report indicated that Patient #1 was scheduled for a first metarsal head cheilectomy (surgery to remove a bony lump on the top of the main joint of the big toe) with subchondral drilling (surgical technique where the surgeon uses a high-speed drill to drill down through a defect in the joint surface and into the underlying bone). Before surgery began, a first year podiatry resident (Podiatry Resident #1) administered a local anesthetic block to the wrong foot, (left). The Attending Podiatrist discovered the error prior to surgery.

1.) Review of the Hospital's Internal Investigation related to Patient #1 receiving the anesthetic block in the wrong foot indicated that the universal protocol was not performed prior to the block. The Attending Podiatrist was not focusing on what the Podiatry Resident was specifically doing because she was looking at another patients radiology imaging studies with a nurse. Podiatry Resident #1 had not completed mandatory education for all new residents in July, because the Podiatry Resident #1 began in October 2011.

The corrective action plan, Action Item #3, indicated that milestones for a podiatry resident's privileges will be established.

The Podiatry Resident was interviewed on 1/4/12 at 12:30 P.M. The Podiatry Resident said that there were 2 podiatry medical students in the OR at the time of Patient #1 (Pt #1) surgery. The Podiatry Resident said he asked the Attending Podiatrist if he could perform the block and the Attending said yes. Podiatry Resident #1 said the Attending Podiatrist was in and out of the OR before Patient #1's surgery comensed. He said Pt #1 did not have a hospital sock on his/her left foot and the podiatry students placed the Webril (gauze dressing) and tourniquet on Pt's #1 ankle (left in error). He said he prepared the block for injection and administered it to Patient #, the left foot in error. He said he did not perform a time out before he gave the block into the patient's foot.

The Chairman of Quality and Safety was interviewed on 1/9/12 at 10:30 A.M. The Chairman of Quality and Safety said that there was a misunderstanding regarding the role of the podiatry medical students. Podiatry Resident #1 thought the podiatry students could assist with direct care. However, the Chairman of Quality and Safety said the podiatry students observe only, they do not touch patients. The Chairman for Quality and Safety said all the Attendings and the two residents have been told that the students observership involves no direct patient care.

The Attending Podiatrist was interviewed on 1/4/12 at 2:40 P.M. The Attending Podiatrist said she told the Podiatry Resident he could administer the block. She said residents learn how to do injections in medical school and she will teach skills for foot surgery. However, she will now always will focus her attention and ensure that all procedures are performed correctly.

Review of the Hospital's Corrective Action Plan indicated that Action Item #3, [Establish milestones for residents privileges that are visible and up to date] had not yet been developed and implemented, so that data related to conducting specific procedures independently from an Attending Podiatrist was accessible.

Based on review of the operative reports and interview with Chairman of Quality and Safety, the Hospital failed to ensure that an operative report was completed by the surgeon immediately following surgery for 6 of 11 patient records (Pt #1, Pt #6, Pt #7, Pt #8, Pt #9 and Pt #11) reviewed.

Findings include:

The Chairman of Quality and Safety was interviewed on 1/9/12 at 10:30 A.M. The Chairman of Quality and Safety said that an operative report must be completed within 24 hours after surgery.


However, review of Hospital Medical Staff Bylaws and Rules and Regulations indicated that the surgeon was required to complete an operative report with the details of the surgical technique, the tissues removed or altered and the post operative diagnosis shall be written or dictated immediately following surgery, for outpatients as well as inpatients.

1.) Pt #1 had surgery on 12/2/11 which was completed at 5:10 P.M. The operative report was dictated on 12/4/11 at 10:00 A.M.

2.) Pt #6 had surgery on 12/9/11 which was completed at 1:20 P.M. The operative report was dictated on 12/10/11 at 10:13 P.M.

3.) Pt #7 had surgery on 12/8/11 which was completed at 1:55 P.M. The operative report was dictated on 12/9/11 at 6:01 A.M.

4.) Pt #8 had surgery on 12/9/11 which was completed at 2:16 P.M. The operative report was dictated on 12/10/11 at 10:16 P.M.

5.) Pt #9 had surgery on 12/8/11 which was completed at 12:52 P.M. The operative report was dictated on 12/9/11 at 6:10 A.M.

6.) Pt #11 had surgery on 1/4/12 which was completed at 1:47 P.M. The operative report was dictated on 1/5/12 at 6:40 A.M.