HospitalInspections.org

Based on clinical record review, policy and procedure review, document review, and interviews, it was determined the Facility failed to follow facility policies and procedures in accordance with acceptable standards of practice. The following failed practices caused harm to Patient #2, and had the likelihood for harm, serious injury or death to all patients that received blood during a surgical procedure.


Review of the document titled Educational Affiliation Agreement, revealed no evidence the SRNA (Student Registered Nurse Anesthetist) that provided services to one of one (#2) Patient was trained and oriented to the operating room. See A-0951


Review of Policy (ON045PCS) and interview, it was determined an identifying label from Patient #1 had been left in the Operating Room (36) after it had been prepared for the surgical procedure for Patient #2. The availability of the label from Patient #1 contributed to the wrong blood to be ordered for Patient #2. See A-0951


Review of Policy ON045PCS, clinical record review, and interview, it was determined the ID (identification) for one of one (#2) Patient was not checked before blood was given during a surgical procedure. This failed practice allowed the wrong blood to be given to Patient #2. See A-0951

Based on review of Policy ON007ADM, document review, and interview, it was determined one of one contracted Student Registered Nurse Anesthetist (SRNA) #1 was allowed to participate in a surgical procedure without evidence of orientation or training. There was no signed Affiliation Agreement for SRNA #1. This failed practice allowed untrained contracted staff to participate in a surgical procedures which resulted in actual harm to Patient #2.


A. There was no evidence Student SRNA #1 had been to any hospital orientation or training for hospital surgery processes and procedures. There was no evidence of an Educational Affiliation Agreement. There was no evidence of a competency based orientation for surgery processes and procedures.


1) Interview with the Director of Compliance at 1230 on 02-17-16 verified the Contracted M.D./CRNA ( Medical Doctor/Certified Registered Nurse Anesthetist) Providers were required by Medical Staff Bylaws to follow the policies and procedures of the Hospital.


2) Policy ON007ADM Student Management Policy-ll. Educational Affiliation Agreement (EAA). "A current Educational Affiliation Agreement (EAA) must be effective and signed by the appropriate Representatives of the institution and the President/CEO of CHI St. Vincent before the student (s) may begin their clinical experience."


B. The above was verified by the Director of Compliance at 1230 on 02-17-16.


2. Based on review of Policy ON029PCS, clinical record review, and staff interview, it was determined blood was ordered for Patient #2 without verifying the identity of Patient #2. This failed practice allowed the wrong blood to be ordered for Patient #2.


A. Policy ON029PCS Perioperative: Environmental Sanitation and Housekeeping in The Operating Room Policy l.B. "Concurrent cleaning and in-between case cleaning will be performed by surgery personnel and /or Environmental Service personnel directed by the Operating Room licensed personnel."


B. Review of the clinical record for Patient #2 revealed the Operating Room Records/Voucher dated 01-13-16 reflected Patient #2 was taken to the Operating Room at 1143, time out was conducted at 1226 and surgery began at 1227.


C. Interview at 0930 on 02-17-16 with the Risk Manager, Director of the Laboratory and Operating Room Supervisor revealed a label from Patient #1, which contained Patient #1's personnel information had been left in Operating Room 36 after cleaning from the surgical procedure performed on Patient #1. The label from Patient #1 was handed out the door of Operating Room 36 and was used to order blood for Patient #2.


3. Based on review of Policy ON045PCS, clinical record review, and interview, it was determined the ID (identification) band for one of one (#2) Patient was not available or checked before blood was given during a surgical procedure. This failed practice resulted in the wrong blood to be given to Patient #2.


A. Review of the clinical record for Patient #2 revealed the Blood Administration Record dated 01-13-16 at 1416 was signed by SRNA (#1) and Certified Registered Nurse Anesthetist (CRNA) #1 for 1 of 2 Units of blood which had the name, medical record number and date of birth for Patient #1. The Blood Administration Record dated 01-13-16, no time recorded, was also signed by SRNA #1 and CRNA #1 for Unit 2 of blood which had the name, medical record number and date of birth for Patient #1.

B. Policy ON045PCS Patient Identification-Policy: l. "Two Identifiers D. Patient identification will be verified making sure the medical record document (MAR, lab label, Blood Administration Record, etc) matches the patient name and date of birth as stated by the patient or on the patient's armband."


C. Interview at 0930 on 02-17-16 with Risk Manager, Director of the Laboratory and Operating Room Supervisor they verified two identifiers for Patient #2 were not checked before two units of blood was administered.