HospitalInspections.org

The Condition of Participation for QAPI was not met.

Findings include:

Based on records reviewed and interview, for one (Patient #1) patient out of 10 sampled patients, the Hospital failed to implement an adequate preventative action for an adverse patient event where the patient required Cardiopulmonary Resuscitation and emergent medical care.


Refer to TAG: A-286

Based on records reviewed and interviews, for one patient (Patient #1) out of 10 sampled patients, the Hospital failed to implement an adequate preventative action for an adverse patient event where Patient#1 required Cardiopulmonary Resuscitation and emergent medical care after a wrong medication administration.

Findings include:

Federal regulations require that performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Review of the Hospital document titled "SVH NRS B.01 The Administration of Medications"indicated that the 6 rights of medication administration are 1. Right Patient 2. Right Drug 3. Right Dose 4. Right Route 5. Right Time 6. Right Documentation. Before administrating any medications, the purpose and potential side effects will be explained, and the medication will be reviewed before administration as a safety check. All Wasted narcotics must be in the presence of 2 RNs and signed on the appropriate paper form, electronic medical record, or medication dispensing machine.

Review of Patient #1's medical record indicated that Patient #1 was scheduled for a mastectomy on 4/15/21. On 4/15/21, Patient #1 arrived at the hospital and was brought to the Pre-operative (Pre-op) area where he/she changed into a hospital gown and was provided a gurney to rest on. At 10:00 A.M. Certified Registered Nurse Anesthetist (CRNA) #1 and Operating Room (OR) nurse #1, met Patient #1 in Pre-op and introduced themselves and began to wheel Patient #1 toward the OR. At 10:01 A.M., CRNA #1 administered 1 ml of a medication ( which was later identified as Rocuronium, a paralytic agent that induces muscle paralysis) intravenously to Patient #1. Patient #1 immediately stopped breathing and was grabbing OR nurse #1's arm but was not able to communicate verbally. A Code Blue (medical emergency) was called. At 10:11 A.M., Patient #1 became pulseless and Cardiopulmonary Resuscitation CPR began. Patient #1 was intubated (placement of a breathing tube) and manual breathing was provided while chest compressions were performed to keep Patient #1's blood circulating. At 10:12 A.M., Patient #1's experienced supraventricular tachycardia (SVT) (an abnormally fast heartbeat) which required cardioversion (a medical procedure by which an abnormally fast heart rate is converted to a normal rhythm using an electric shock) using 100 joules of electricity. At 10:14 A.M., Patient #1 was cardioverted again using 200 joules of electricity. At 10:23 A.M., Patient #1 was transported to the Intensive Care Unit (ICU).

During a telephone interview on 5/3/21, at 12:15 P.M., the Chief of Anesthesia said that he became aware of this incident soon after it occurred. The Chief of Anesthesia said that he interviewed CRNA #1 on the day of the incident. The Chief of Anesthesia said that CRNA #1 thought he/she gave Midazolam (medication used to produce sleepiness and relieve anxiety).The Chief of Anesthesia said that the sharps container that CRNA #1 disposed his/her medication syringe in Pre-op was removed and a syringe containing Rocuronium was found in the sharps container. The Chief of Anesthesia acknowledged that the syringe was the same syringe that CRNA#1 used when administering medication to Patient #1. The Chief of Anesthesia said that Rocuronium should never be carried out of the OR rooms and medication should never be pre-drawn (Drawing medication into a syringe from a vial). The Chief of Anesthesia said that medications are to be drawn up at the patient's side after proper identification and then administered. The Chief of Anesthesia said that as a corrective action, on 4/21/21, he held an Anesthesia meeting and reviewed the policy of point of care medication administration with Anesthesia staff. The Chief of Anesthesia said that he sent an email to the Anesthesia staff who did not attend the meeting.

Review of the 4/21/21 Anesthesia meeting indicated that only 29 staff members out of the 42 member Anesthesia Department attended the meeting.

Review of the Chief of Anesthesia's email, dated 4/23/21, at 9:22 A.M., was addressed to the Anesthesia Department staff and indicated that policies were reaffirmed during the meeting and required attention. The Chief of Anesthesia's email also indicated that Medication can be taken to Preop for point of care administration. The Chief of Anesthesia's email did not describe the steps in point of care administration or provide an explanation of what point of care testing was. The email did not review the policy for Administration of Medication, which was not adhered to at the time of the incident. The email indicated that proper disposal and waste of medications; controlled medications needs a witness attestation. The email had no read receipt.

On 5/3/21, the Director of Clinical Quality, acknowledged that there was no Hospital policy for "point of care medication administration", and the hospital could provide no evidence that the Anesthesia staff read or acknowledged the email from the Chief of Anesthesia.

The Condition of Participation for Anesthesia Services was not met.

Findings include:

Based on records reviewed and interview, for one (Patient #1) patient out of 10 sampled patients, the Hospital failed to implement an adequate preventative action for a medication error involving Anesthesia where the patient required Cardiopulmonary Resuscitation and emergent medical care.

Findings include:

Federal regulations require the hospital to assure that any staff administering drugs for analgesia must be appropriately qualified, and that the drugs are administered in accordance with accepted standards of practice.

Review of the Hospital document titled "SVH NRS B.01 The Administration of Medications"indicated that the 6 rights of medication administration are 1. Right Patient 2. Right Drug 3. Right Dose 4. Right Route 5. Right Time 6. Right Documentation. Before administrating any medications, the purpose and potential side effects will be explained, and the medication will be reviewed before administration as a safety check. All Wasted narcotics must be in the presence of 2 RNs and signed on the appropriate paper form, electronic medical record, or medication dispensing machine.

Review of Patient #1's medical record indicated that Patient #1 was scheduled for a mastectomy on 4/15/21. On 4/15/21, Patient #1 arrived at the hospital and was brought to the Pre-operative (Pre-op) area where he/she changed into a hospital gown and was provided a gurney to rest on. At 10:00 A.M. Certified Registered Nurse Anesthetist (CRNA) #1 and Operating Room (OR) nurse #1, met Patient #1 in Pre-op and introduced themselves and began to wheel Patient #1 toward the OR. At 10:01 A.M., CRNA #1 administered 1 ml of a medication ( which was later identified as Rocuronium, a paralytic agent that induces muscle paralysis) intravenously to Patient #1. Patient #1 immediately stopped breathing and was grabbing OR nurse #1's arm but was not able to communicate verbally. A Code Blue (medical emergency) was called. At 10:11 A.M., Patient #1 became pulseless and Cardiopulmonary Resuscitation CPR began. Patient #1 was intubated (placement of a breathing tube) and manual breathing was provided while chest compressions were performed to keep Patient #1's blood circulating. At 10:12 A.M., Patient #1's experienced supraventricular tachycardia (SVT) (an abnormally fast heartbeat) which required cardioversion (a medical procedure by which an abnormally fast heart rate is converted to a normal rhythm using an electric shock) using 100 joules of electricity. At 10:14 A.M., Patient #1 was cardioverted again using 200 joules of electricity. At 10:23 A.M., Patient #1 was transported to the Intensive Care Unit (ICU).

During a telephone interview on 5/3/21, at 12:15 P.M., the Chief of Anesthesia said that he became aware of this incident soon after it occurred. The Chief of Anesthesia said that he interviewed CRNA #1 on the day of the incident. The Chief of Anesthesia said that CRNA #1 thought he/she gave Midazolam (medication used to produce sleepiness and relieve anxiety).The Chief of Anesthesia said that the sharps container that CRNA #1 disposed his/her medication syringe in Pre-op was removed and a syringe containing Rocuronium was found in the sharps container. The Chief of Anesthesia acknowledged that the syringe was the same syringe that CRNA#1 used when administering medication to Patient #1. The Chief of Anesthesia said that Rocuronium should never be carried out of the OR rooms and medication should never be pre-drawn (Drawing medication into a syringe from a vial). The Chief of Anesthesia said that medications are to be drawn up at the patient's side after proper identification and then administered. The Chief of Anesthesia said that as a corrective action, on 4/21/21, he held an Anesthesia meeting and reviewed the policy of point of care medication administration with Anesthesia staff. The Chief of Anesthesia said that he sent an email to the Anesthesia staff who did not attend the meeting.

Review of the 4/21/21 Anesthesia meeting indicated that only 29 staff members out of the 42 member Anesthesia Department attended the meeting.

Review of the Chief of Anesthesia's email, dated 4/23/21, at 9:22 A.M., was addressed to the Anesthesia Department staff and indicated that policies were reaffirmed during the meeting and required attention. The Chief of Anesthesia's email also indicated that Medication can be taken to Preop for point of care administration. The Chief of Anesthesia's email did not describe the steps in point of care administration or provide an explanation of what point of care testing was. The email did not review the standard of practice for correct medicaiton administration or the policy for Administration of Medication, which was not adhered to at the time of the incident. The email indicated that proper disposal and waste of medications; controlled medications needs a witness attestation. The email had no read receipt.

On 5/3/21, the Director of Clinical Quality, acknowledged that there was no Hospital policy for "point of care medication administration", and the hospital could provide no evidence that the Anesthesia staff read or acknowledged the email from the Chief of Anesthesia.

Based on observation and interview the Hospital failed to consistently adhere to safe medication practice.

The Surveyor observed the pre-procedure set up of Operating Room #5 at 9:00 A.M. on 4/27/2021. The Surveyor noted a syringe filled with clear fluid attached to a three-way cockstop on extension tubing on the top shelf of the anesthesia pyxis machine (an automated medication dispensing cabinet). The syringe was labeled as 4/23/21 (four days prior).

The Chief of Anesthesia Services was interviewed at 9:20 A.M. on 4/27/2021. The Chief of Anesthesia Services said the syringe should have been discarded after the case it was drawn up for was competed.