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MONTEFIORE MEDICAL CENTER
PATIENT SAFETY
Tag No.: A0286
Based on medical record review, document review and staff interviews, there was no documentation that the facility tracked, analyzed and implemented corrective actions for incidents related to self extubation and unplanned removal of central lines.
Findings include:
Review of the facility incident reports from May 2017 to August 2017 revealed 45 incidents of unplanned endotracheal extubations (removal of breathing tubes), accidental removal of central lines and large bore venous access catheters (large diameter venous to arterial devices usually used in dialysis).
Review of the Quality Improvement minutes from January 2017 to August 2017 revealed no documentation that the facility tracked and analyzed the data collected to determine if corrective or other quality improvement action was warranted.
During interview on 9/6/17 at 2:25PM with Staff CC, Medical Director of Critical Care, he stated that each incident is discussed at the time of occurrence but the facility does not track, analyze or document any review findings.