HospitalInspections.org

Based on interviews and document review, it was determined the facility staff failed to follow policies and procedures which caused one (1) patient to be subjected to the administration of a contrast dye and radiology scan that was ordered for a different patient.

The findings include:

On 9/8/21 the Surveyor conducted a review of the medical record for Patient #1. A note from the provider, Staff Member #3, reveals that Patient #1 has a history of end stage renal disease and is now on hemodialysis, came to the ED by ambulance with bleeding from the fistula. Staff Member # 3 stated, " While [Patient #1]was in the emergency department [Patient #1] received accidental CTA of [the] chest. Patient #1 received IV contrast. Discussed with on-call nephrologist who recommends that patient gets dialyzed today and again tomorrow. Offered Patient hospitalization, however [Patient #1] declines."

On 9/7/21 the Surveyor conducted an interview with Staff Member # 3, an ED physician. Staff Member #3 explained what occurred with Patient #1. When treated in the ED, there was "a failure in identifying the patient." A telephone conversation occurred between Staff Member # 6 and Staff Member #7 in which they "referred to the patient by room number, instead of name". A CTA scan was ordered for the patient in room number 22 so when the call was made to bring the patient over, Staff Member #6 transported Patient #1, who was in room 23, to the radiology suite for the test. Staff Member #7 then performed a CTA scan, after giving Patient #1 contrast dye.

Staff Member # 3 stated that when the error was realized, Patient #1's Nephrologist was informed and consulted. When the patient showed signs of itching Staff Member #3 ordered medication to treat this. Staff Member #6, gave the medication as ordered. Patient #1 was offered to stay in the hospital for further care, but did not want this option. Patient #1 "had an appointment already scheduled later in the morning with the Surgeon who normally cares for the fistula" and wanted to keep it. Patient #1 was then discharged.

The Policy, "Patient Identification During Admission and Treatment" states in part, "It is the policy of Inova Health System to provide safe care and accurate patient identification. Two patient identifiers are always used whenever interacting with or referring to patients. This includes but is not limited to diagnostic testing...medication administration...transport/handoffs between departments. The two identifiers used are: full name, and date of birth (month/day/year)."

This policy also states, "During the encounter at Inova Health System, the patient will NEVER be referred to by room number, procedure or diagnosis.

Proper Patient Identification
Prior to any care, handoff...treatment and services: the team member is required to ask the patient to state their full name and date of birth as ID band is reviewed for accuracy of information.

2. Radiology/diagnostic testing: Team member will read out loud the last 4 digits of the medical record number (MRN) on the patient ID band to confirm the ordered diagnostic test prior to initiating."

On 9/8/21 the Surveyor reviewed the document "Contrast Allergy Protocol". The document states in part, "The following document will be followed:
1. Every patient will be questioned by the technologist about prior history of contrast allergy or contrast reaction. "


The Policy, "Contrast Media-Pre and Post Injection", states in part,
"Procedure:
A. Contrast Media History
1. The technologist will ask the patient their history with Iodinated Contrast Media to determine if patient has any contraindications to Iodinated Contrast Media."