HospitalInspections.org

Based on interview and document review, the hospital's quality assurance/performance improvement (QAPI) program failed to investigate and analyze an adverse patient event in which a patient mistakenly received an injection of air intravenously while undergoing a CT scan in the radiology department. The radiology department had conducted an investigation, but the event was not reported to the hospital's QAPI program thereby missing an opportunity for review and analysis by the hospital's patient safety officer. Findings are:

A complaint was received by the New York State Department of Health (NYSDOH) on 8/20/2014 describing an event of an inadvertent intravenous injection of air into a patient occurring in July 2014. An unannounced complaint investigation survey was conducted at the facility on 8/22/2014. An interview conducted with the hospital's vice president for quality and safety at approximately 10:30 AM revealed there was no incident report or patient safety investigation of the alleged event. Upon reviewing the log of radiology procedures for July 2014, the hospital patient safety officer identified that on 7/9/2014, at 11:17 AM a patient had undergone a CT of the chest, abdomen, and pelvis with contrast in the outpatient radiology department and at 3:10 PM, another CT of the chest was performed on the same patient. A review of the radiology reports for both exams indicated that the morning scan of the chest showed gas in the right ventricle, main pulmonary artery, superior vena cava, and right upper extremity veins. The afternoon scan of the patient's chest shows complete resolution of the gas. Air in a patient's vascular system can cause death or injury in a patient.

The NYSDOH investigation determined that radiology staff failed to file an incident report with the hospital patient safety officer. This was confirmed with the hospital's patient safety officer on 8/22/2014 at 10:30 AM. Interview of the hospital administration's executive assistant conducted on 8/22/2014 at 12:30 PM revealed that incident reports from hospital departments are submitted to her, logged in and then given to the hospital's patient safety officer for review. The executive assistant confirmed in this interview that she had not received an incident report regarding this event from the radiology department.