HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure that potentially faulty equipment was sequestered following a patient safety event for 1 of 1 patients reviewed (Patient #1).

Failure to sequester equipment risks inaccurate Root Cause Analyses and additional patient harm.

Findings included:

1. Document review of the hospital policy titled, "Serious Event Policy," PolicyStat ID 9961029, revised 06/21, showed that staff should:

a. Immediately collect and secure all available physical evidence that may assist in the investigation of the event.

b. Remove involved equipment from service, tag it, and store in a secured area.

2. Document review of the Electronic Medical Record (EMR) showed:

a. On 08/11/23 at 3:42 AM, Patient #1 presented to the Emergency Department (ED) with neck, chest and abdominal pain since 9:00 PM on 08/10/23.

b. Registered nurses(RNs) started an IV in each of Patient #1's arms for infusion of normal saline, antibiotics, and blood pressure medications.

c. At 5:30 AM, Patient #1 had a cat scan of her chest.

d. At 6:16 AM, a radiology report stated air in the right ventricle and multiple large central veins. This is presumably iatrogenic (caused by medical action or treatment).

3. On 09/01/23 at 2:30 PM, an interview with the Manager of Patient Safety and Risk Management (Staff #1) showed that hospital staff did not sequester the infusion pumps or CAT scan contrast injector used for Patient #1.

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