HospitalInspections.org

Based on observation, document review and staff interviews, the Hospital's administrative staff failed to ensure 1 of 1 observed Certified Registered Nurse Anesthetists (CRNA A) cleansed the stopper on medication vials prior to removing the medication from the vials for 1 of 1 observed surgical patients (Patient #1). Failure to cleanse the stopper could potentially result in the staff introducing bacteria, viruses, or fungi into the medication and then administering the contaminated medication to the patient. Administering contaminated medication could potentially result in the patient developing a life threatening infection. The Hospital's administrative staff identified the surgical services staff performed an average of 616 surgical procedures per month over the last 6 months.

Findings include:

1. Observations on 12/31/19, beginning at 12:13 PM, in OR #15 while staff set up the room for Patient #1's surgery, revealed the following:

a. CRNA A (a nurse with specialized training to administer the medications used during surgery to ensure patients do not feel pain during surgery) removed the plastic cover on the top of the medication vial and removed Propofol 200 MG (drug used for anesthesia and sedation) using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

b. CRNA A removed the plastic cover on the top of the medication vial and removed Lidocaine 1% 50 MG (drug used to numb an area of the body) from the vial using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

c. CRNA A removed the plastic cover on the top of the medication vial and removed Succinycholine 120 MG (a medication used to relax muscles during surgery) from the vial using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.


2. Review of document "MercyOne Medication Administration," last approved 07/2019, revealed in part, "Aseptic technique is utilized when preparing and administering parenteral medications. This includes always entering a medication or intravenous line with a sterile needle and sterile syringe. Vials will be cleansed with an antiseptic wipe prior to puncturing...."

3. During an interview at 2:15 PM on 12/31/19 CRNA A confirmed that he did not remember if he cleansed the vial stopper on the first 3 medication vials prior to removing the medication from the vials.