HospitalInspections.org

Based on a review of facility documents and interviews with staff (EMP), it was determined that the facility failed to follow their established policy related to the reporting of unusual events.

Findings include:

Review of Somerset Hospital ... PolicyStat ID: 2920191 ... Last Reviewed: 10/2016 ... Policy Area: Management ... Event Reporting, revealed, "... Policy Statement: To provide Somerset Hospital employees with a guideline for filing event reports and to assure that all events and potential events identified are investigated and acted upon. Somerset Hospital will provide the appropriate information for reporting events in an effort to maintain a safe working environment for employees, visitors, physicians, volunteers, students and patients. Associated Information: Attachments: Procedure: The Event Reporting System is one of the essential identifiers within the Performance Improvement Program. An event is an incident that is not consistent with routine care of a patient, routine service of a department, or routine operation of the facility. The event includes unusual occurrences, injuries, accidents and situations which have caused an accident or could develop into an accident. Patients, visitors, physicians, students, volunteers, and employees may be involved. The report filed shall be a factual account of the details of the event. This provides a method for discovery and means for investigation of the cause. A tracking system has been implemented for processing event reports to assure and provide a comprehensive system that is integrated and coordinated with the monitoring and evaluation process. Event Reports: The Event Report is primarily a management tool used to prevent and avoid the recurrence of incidents. Thoughtful use of the event data provides the hospital with meaningful, information for the purpose of risk identification and the charting of event trends. All employees are required to report adverse events (regardless of severity) as well as potential (near miss) events to the Risk Manager. The electronic event report must be completed by the employee who first identifies the event. Event Investigation: The Risk Manager strives to identify liability claims expediently so that the hospital is in better position to defend itself by reviewing completed Event reports and verbal communication with those involved in the events."

1) A review of facility documents revealed that on 12/1/2016, debris was found on the sterile field by EMP7 at the end of the surgical case. Continued review of facility documents revealed that an internal report was not completed until 12/6/2016.

2) An interview conducted by phone on 1/11/2017, with EMP8 confirmed there was a delay of five days in the event being identified and the report being completed and submitted.