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Based upon record review and interviews, the medical staff and administration failed to ensure the medical staff bylaws, rules and regulations, included provision for the utilization and appointment of a medical student. A medical student was not clear to participate in clinicals and/or shadowing providers in the Operating Room. The medical staff and administration did not have clear communication with the medical student and with the departments involved in clinicals. The supervision of the medical student clearance and confirmation of a signed memorandum of understanding from the medical school was not completed and this fact was not clearly communicated to the medical student, the providers and operating room leadership.


Review of the Medical Staff Bylaws, Rules and Regulations revealed the section in the Rules and Regulations titled, "Medical Students" Section 8.04, states "There is a signed Memorandum of understanding from the medical school and verification that the student has liability coverage and is in good standing." Further review found of the section revelated that "The medical student must have appropriate identification issued by the Operating Room Director".



An interview was conducted with staff #1 on 9/12/2024 at 1:00 pm at Northeast Baptist Hospital. Staff #1 reported she remembered the issue regarding the staff member/medical student shadowing a surgeon at Northeast Baptist and North Central Baptist hospital. Staff #1 stated that the medical student had shadowed the surgeon multiple times at both facilities. Staff #1 stated that the issue was identified when a staff member asked for the medical student credentials, which he was unable to produced. Staff 1 stated that an internal investigation was conducted. Staff #1 revealed that the investigation resulted on a reprimand of the medical student/staff member, a provider peer review and education for the staff. The investigation also revealed that the Graduate Medical Education department never completed the Affiliation Agreement or Memorandum of Understating with the medical school attended by the medical student.

An interview was conducted with staff #3 on 9/12/2024 at 1:35 PM at Northeast Baptist. Staff #3 stated that she had confronted the staff member/medical student once he was seen in the Operating Room area. Staff #3 stated that the medical student could not produce any credentials nor documentation to confirm that he was allowed to assist or shadow a provider on a surgical case. Staff #3 stated that management was not aware of this medical student and that it took some time to confirm that he was not cleared to participate in clinicals at the facility.

An interview was conducted with staff #4 on 9/12/2024 at 2:00 pm at Northeast Baptist. Staff #4 stated that the staff did not complete the process to clear the medical student to participate in clinicals. Staff #4 stated that it was a unique case as the medical student was also a Anesthesia technician with access with his employee badge to the operating rooms. Staff #4 stated that education regarding bylaws and proper identification of students in clinicals was provided to the medical staff. Staff #4 also stated that a peer review was conducted to review the providers' actions. Staff #4 stated that there was no previous history of such event.

An interview was conducted with staff #5 on 9/13/2024 at 11:00 AM via telephone. Staff #5 stated that she manages 400 medical student a year in her department. Staff #5 stated that the medical student involved had communicated via email to obtained clearance for clinicals. Staff #5 stated that this was the first time trying to complete an affiliation agreement with this medical school in central America. Staff #5 stated that she made several attempts to complete the process, yet some documents were never completed by the medical school. Staff #5 stated that she informed the medical student the documentation was not complete by the medical school. Staff #5 stated that she was not sure if an email or communication was sent to the medical student or providers involved stating that the medical student was not cleared for clinicals.

An interview was conducted with the medical student on 9/16/2024 at 9:00 AM. The student stated that he started the process to get cleared for clinicals at the facilities. The student stated that he was in contact with the school of medicine and the office of Graduate Medical Education. He stated that he never received or was aware of any email stating that he was not cleared for clinicals. He stated that he was embarrassed and troubled when he was pulled from a case and told he was not cleared for clinicals.

A review of email records from the office of Graduate Medical Education (GME) revealed that emails had been exchanged between the medical student, the GME department and the school of medicine. The emails showed that there was communication with the medical school requesting the missing documents. The emails do not show a resolution and no email was found stating to the medical student that he was not cleared for clinicals. No email communication was noted with the providers involved. The review of the emails did not reveal any coordination with the Operating room management.