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Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure that the patient received care in a safe setting by failing to follow their adopted Patient's Bill of Rights related to the prevention of personal discomfort of a patient in one of two medical records reviewed. (MR2)

Findings include:

Review of UPMC Bedford Memorial's administrative policy entitled "Patient Rights/Organizational Ethics Policy", dated June 2010, revealed "It is the policy of UPMC Bedford Memorial to promote the interests and well being of patients served ... ."

Review of "Patient Rights", effective October 2010, revealed "At UPMC, service to our patients and their families or representatives is our top priority. We are committed to making the hospital stay or outpatient service as pleasant as possible. We have adopted the following Patient Bill of Rights to protect the interests and promote the well-being of those we serve ... For your plan of care, you have a right: To participate in the development and implementation of your plan of care, including pain management and discharge planning; To make informed decision regarding your care, treatment, or services, by being: informed in language or terms you can understand; fully informed about your health status, diagnosis, and prognosis, including information about alternative treatments and possible complications ... involved in care planning and treatment; informed about the outcomes of care, treatment or services that you need in order to participate in current and future health care decisions ... Regarding quality, support, and advocacy, you have the right: ... to quality care and high professional standards that continually are maintained and reviewed; to have the facility implement good management techniques that consider the effective use of your time and avoid your personal discomfort ... ."

1) Review of MR2 revealed the patient presented to the ED and was discharged with a diagnosis of urinary tract infection and flank pain. The patient was ordered a CT scan, and was subsequently discharged. The record stated that the previous evening the patient had a diagnosis of early appendicitis, but the results were placed on another patient's chart and a normal CT scan was placed on the patient's chart. The patient was then contacted at home and was instructed to return to the hospital, and was taken to the operating room for an appendectomy.

2) Interview with EMP3 on February 15, 2011, at approximately 10:30 AM, revealed "...I am not sure what went wrong. We get the scan reports via fax ... Whoever is closest to the fax machine or whoever hears it first, just grabs the report off the machine and hands it to the doctor or puts it in the chart. I took the report off the fax and handed it to OTH1 ... OTH1 looked at the report and handed it to EMP7 ... It was just human error, none of us looked at the name. Every time that I take a report off the fax now, I make sure to look at the name ... Even though we read the reports wrong, it made sense to us based on how each (patient) presented ... ."

3) Interview with EMP7 on February 15, 2011, at approximately 11: 30 AM, revealed "... We did send (the patient) home based on (another patient's) study. I got a call from OTH1 the next day, (who) said they sent ... the wrong study. I made a few calls and I saw the mistake right away. We notified (the patient) and had (the patient) come back in ... ."

4) Interview with (EMP2), on February 15, 2011, at approximately 1:50 PM, revealed "They are circling the name to bring attention to it. It was pure human error. Nothing mechanical failed ... ."

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure that the correct roentgenologic findings were present on the correct record for two of 12 medical records reviewed. (MR1, MR2)

1) Review of MR1 revealed the patient presented to the ED and the Treatment Plan consisted of a CT scan of the abdomen and pelvis that demonstrated acute appendicitis. Review of the facsimile report of the CT scan did not reveal findings of acute appendicitis.

Review of MR2 revealed the patient presented to the ED and was discharged with a diagnosis of urinary tract infection and flank pain. The patient was ordered a CT scan, and was subsequently discharged. The record stated that the previous evening the patient had a diagnosis of early appendicitis, but the results were placed on another patient's chart, and a normal CT scan was placed on the patient's chart. The patient was then contacted at home and was instructed to return to the hospital, and was taken to the operating room for an appendectomy.

2) Interview with EMP3 on February 15, 2011, at approximately 10:30 AM, revealed "...I am not sure what went wrong. We get the scan reports via fax ... Whoever is closest to the fax machine or whoever hears it first, just grabs the report off the machine and hands it to the doctor or puts it in the chart. I took the report off the fax and handed it to OTH1 ... OTH1 looked at the report and handed it to EMP7 ... It was just human error, none of us looked at the name. Every time that I take a report off the fax now, I make sure to look at the name ... Even though we read the reports wrong, it made sense to us based on how each (patient) presented ... ."

3) Interview with EMP7 on February 15, 2011, at approximately 11: 30 AM, revealed "... we had several patients going to CT scan at the same time. We get the CT reports on the fax right next to us ... We were waiting on both reports when one came back, it was positive for acute appendicitis. OTH1 picked it up and went over to the patient and told (the patient) that (the patient) had appendicitis. I called the surgeon on call, it was EMP14. EMP14 looked at (the patient's) CT film from ... home and decided to admit (the patient) and monitor (the patient) overnight. EMP14 did not have the paper report that we had, EMP14 was looking at (the patient's) film and was not convinced that it was (the patient's) appendix ... I guess that (the other patient's) report, in paper form, was transposed on the charts ... We did send (the other patient) home based on (another patient's) study. I got a call from OTH1 the next day, (who) said they sent ... the wrong study. I made a few calls and I saw the mistake right away. We notified (the other patient) and had (the other patient) come back in ... ."

4) Interview with (EMP2), on February 15, 2011, at approximately 1:50 PM, revealed "They are circling the name to bring attention to it. It was pure human error. Nothing mechanical failed ... ."

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow adopted policies related to preoperative verification of relevant documentation for one of two medical records reviewed. (MR1)

Findings:

Review of UPMC Bedford Memorial's administrative policy entitled "Universal Protocol", dated April 2010, revealed "The goal of this policy is to prevent wrong site, wrong procedure, and wrong person surgery. In developing this policy consensus was reached on the following principles: Wrong site, wrong procedure, wrong person surgery must be prevented. Multiple, complementary strategies are used to achieve this goal. Active involvement and effective communication among all staff members is essential for success. To the extent possible the patient (or legally designated representative) should be involved in the process. Consistent implementation of a standardized approach using a universal, consensus-based protocol will be most effective. It is intended that the policy be flexible enough to allow for implementation with appropriate adaptation when required to meet specific patient needs ... The universal protocol should be applicable or adaptable to all operative and other invasive procedures that expose patients to harm, including procedures done in settings other than the operating room. In concert with these principles, the following steps, taken together, comprise the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surgery. Pre-operative verification process: Purpose: To ensure that all of the relevant documents and studies are available prior to the start of the procedure and that they have been reviewed and are consistent with each other and with the patient's expectations and with the team's understanding of the intended patient, procedure, site and, as applicable, any implants. Missing information or discrepancies must be addressed before starting the procedure. Process: An ongoing process of information gathering and verification, beginning with the determination to do the procedure, continuing through all settings and interventions involved in the preoperative preparation of the patient, up to and including the "time out" just before the start of the procedure ... A preoperative verification checklist will be utilized to ensure the availability and review of the following, prior to the start of the procedure: 1. Relevant documentation including H&P, consent, test results. 2. Relevant images, properly labeled and displayed. 3. Any required implants and/or special equipment ... ."

1) Review of MR1 revealed Universal Protocol Time Out documentation, which indicated "yes" to relevant diagnostic/radiology test results, available, labeled and appropriately displayed.

2) A telephone interview with (EMP12), on February 17, 2011, at 11:00 AM, was conducted. When queried regarding the documentation in MR1, EMP12 stated "we only do that if the doctor wants the results displayed. I did check (the patient's) ID band, but I didn't read over all (the patient's) tests. I am trusting that somebody does that before I get the patient. There are many checks before I get the patient. From now on, I will be looking at the names on the papers."