HospitalInspections.org

Based on review of facility policies, documentation and interview with staff (EMP), it was determined the facility failed to ensure that biopsies were obtained in a safe manner during upper and lower endoscopy procedures for 51 of 51 outpatients from February 18, 2013, to March 25, 2013. (MR1 to MR51)

Findings include:

Review on May 20, 2013, of the facility's "Policy No.112.09 Patient Right and Responsibilities" last reviewed 1/17/2013, revealed "The Statement on Patient Rights and Responsibilities is posted in appropriate location throughout TJUH hospital facilities ... . Copies are also available in outpatient and ambulatory areas throughout the hospital facilities ... . Patients have the right to excellent, quality health care, maintained to the highest professional standards ... ."
Interviews conducted on May 20, 2013, 9:15 AM with EMP1 and EMP2 confirmed that on 14 days ranging from February 18, 2013, to March 25, 2013, 51 patients had either upper or lower endoscopies with multiple biopsies performed in the main hospital's outpatient endoscopy suite. It was confirmed that in all 51 patients cases either EMP9 or EMP10 reused the same rinse water to rinse the forceps between biopsies for multiple patients.

An interview conducted on May 20, 2013, at 10:00 AM with EMP3 revealed, "The surgical tech and the nurse involved did not follow the hospital's policies and procedures."

An interview conducted on May 20, 2013, at 10:45 AM with EMP4 confirmed "As soon as the breech in infection control practices was identified, the two staff were removed from service. When the tech who reused the rinse water was questioned, they said that they thought they were making the process more efficient and did not pick up the fact that they were breaking protocol."