HospitalInspections.org

Based on policy and procedure review, closed medical record reviews, incident report log review, and staff interviews, facility staff failed to ensure tracking of patient safety events by failing to complete an incident report for 1 of 5 records that documented intravenous (IV) infiltration of contrast during computed tomography (CT) scan (Patient #4).

The findings included:

Review of "Occurrence Management and Reporting - Patient, Visitors, Equipment" revised date 07/2015, revealed "...DEFINITONS: Occurrence: is defined as an event resulting in actual injury or which represents a risk of injury to a patient, visitor, hospital employee, property, equipment or supplies. POLICY: An occurrence report is completed immediately by hospital personnel having first hand knowledge of an occurrence or near occurrence... The department Manager completes an Event Investigation and forwards to the Department Director for final updates and completion. ..."

Closed medical record review of Patient (Pt) # 4, on 03/27/2018, revealed the patient, a 60-year-old female presented to the Emergency Department (ED) on 01/20/2018 with complaint of right groin hematoma. Review revealed a physician order written on 01/20/2018 at 0502 for a CT abdomen pelvis with contrast. Review of an ED note dated 01/20/2018 at 0647 revealed Registered Nurse (RN) was notified by CT of a peripheral intravenous (PIV) contrast to left forearm infiltrated (contrast leaked into the surrounding tissue). Continued review revealed the IV was removed, ice applied to the left forearm and extremity was elevated. Review of the CT result dated 01/20/2018 revealed the patient was given 160 cubic centimeter (cc) of Omniqapue 350 (contrast) IV with the initial 80cc dose infiltrated in the IV site. Review of the ED physician note at 0656 revealed after the patient's return from CT scan around 0630 to 0700, the right arm was elevated and there was some tenderness that was noted in the right arm with no vascular impairment. Review of a two-view X-Ray of Pt #4 right forearm dated 01/20/2018 at 1247 revealed extensive contrast extravasation (accidental infiltration of a drug into the surrounding IV site which may cause tissue destruction) in the right forearm extended from the base of the hand to the level of the elbow. Review of the History and Physical (H&P) dated 01/20/2018 at 1533 revealed Pt #4 was admitted under observation with principal problem of IV infiltration of right forearm with contrast. Continued review revealed Pt #4 had significant pain and swelling.

Review of Incident Report Log for the month of January 01, 2018 to present on 03/27/2018 revealed no documentation of an incident of IV infiltration for Pt #4.

Telephone interview with CT Tech (technician) #1, on 03/28/2018 at 1605, revealed CT Tech #1 cared for Pt # 4 on 01/20/2018 when Pt #4 had the IV contrast infiltration to the right arm. Interview revealed CT Tech #1 placed a cold pack on the arm, elevated the extremity and notified the ED physician and the nurse. Interview revealed CT Tech #1 did not complete an incident report by the end of his shift. Interview revealed CT Tech #1 notified the Weekend Coordinator of the infiltration and would complete the incident report the next day. Further interview revealed CT Tech #1 was sick and did not return to work until several days later and it was outside of the timeframe for the incident reporting period.

Interview with Administrative Staff (AS) # 1, on 03/27/2018 at 1300, revealed IV infiltrations with contrast should be considered severe due to its nature as an irritant. Interview revealed all IV infiltrations with contrast warrant an incident report and an incident report should have been completed for this occurrence.

Interview with Administrative Staff (AS) # 1, on 03/28/2018 at 1640, revealed incidents reports were to be completed at the end of an employee's shift. Interview confirmed policy was not followed.

Based on policy and procedure review, closed medical record reviews, and staff interviews, facility staff failed to adminster IV contrast according to established process for 1 of 5 records that documented intravenous (IV) contrast during computed tomography (CT) scan (Patient #4).

The findings included:

Review of the facility's policies and procedures on 03/28/2018 revealed there was no specific policy or procedure on IV contrast administration using the dual-head power injector (automated contrast media injector system with simultaneous injection of contast media and saline).

Closed medical record review of Patient (Pt) # 4, on 03/27/2018, revealed a 60-year-old female presented to the Emergency Department (ED) on 01/20/2018 with complaint of right groin hematoma (collection of blood outside of a blood vessel). Review revealed a physician order written on 01/20/2018 at 0502 for a CT scan of the abdomen and pelvis with contrast. Review revealed Pt #4 had a 22 gauge (G) IV placed to the right forearm on 01/20/2018 at 0614 prior to leaving the ED to the Radiology Department. Review of an ED note dated 01/20/2018 at 0647 revealed Registered Nurse (RN) was notified by the CT department of a peripheral intravenous (PIV) contrast infiltration (contrast leaked into the surrounding tissue) to the right forearm. Review of the CT scan result dated 01/20/2018 revealed the patient was given 160 cubic centimeter (cc) of Omniqapue 350 (contrast) IV with the initial 80cc dose infiltrated in the IV site. Review of a two-view X-Ray of Pt #4 right forearm dated 01/20/2018 at 1247 revealed extensive contrast extravasation (accidental infiltration of a drug into the surrounding IV site which may cause tissue destruction) in the right forearm extended from the base of the hand to the level of the elbow. Review of the History and Physical (H&P) dated 01/20/2018 at 1533 revealed Pt #4 was admitted under observation with principal problem of IV infiltration of right forearm with contrast. Continued review revealed Pt #4 had significant pain and swelling.

Review of the dual-head power injector, on 03/28/2018 at 1530, revealed on 01/20/2018 at 0619 Pt #4 had a CT of the abdomen and pelvis with the dual-head power injector set on:
Average Contrast Injection Rare: 1.5ml (milliliter)/sec (second)
Contrast Volume: 97 ml
Saline Rate: 1.5ml/sec
Saline Volume given: 2 ml
Average PSI (pound per square inch): 98
Maximum PSI: 115
Maximum PSI Setting: 300

Telephone interview with CT Tech (technician) #2, on 03/28/2018 at 1250, revealed prior to any CT scans ordered with IV contrast, the CT Tech would manually flush the patient's IV with normal saline (NS) using a 10 cc syringe. If met with resistance during the flush, the tech may reposition the arm with the IV above the patient's head and repeat the flush. Interview revealed post the manual flush, the dual-head power injector would be set with one syringe with NS and one syringe with the contrast to be given. Interview revealed prior to injecting the patient with the contrast, a mechanical flush was done by the power injector at or about the same rate as the contrast to mimic the pressure at which the contrast would be given. Interview revealed the mechanical flush was done to assess the capacity of the vein. Interview revealed the rate of the contrast was driven by the protocol depending on the IV size. Interview revealed for CT of the abdomen and pelvis the rate of the contrast should be 2-3 cc/sec for a 20G IV placed above the wrist; and less than 2 cc/sec for an IV smaller than 20G or an IV placed on the patient's hand. The purpose of the mechanical flush was to make sure the vein will hold up to the pressure of the contrast injection. The mechanical flush was as important as the manual flush.

Telephone interview with CT Tech #1, on 03/28/2018 at 1605, revealed the process was to set the dual-head power injector with 50 ml of NS and 100 ml of contrast. Interview revealed the CT Techs had the ability to stop the NS at any time if there was no complaint from the patient. Interview revealed the power injector had a button to hold down to while doing the NS test. Interview revealed "maybe I did not hold the button down long enough". The amount of NS used was indicated on the monitor of the power injector, "but I don't pay attention to the amount on the monitor. I go by the patient's reaction". Further interview revealed the mechanical test flush was another test to make sure the vein will hold up to the pressure of the contrast injection. The mechanical flush was as important as the manual flush.

Interview with Radiology Technician (RT) - Supervisor/Trainer on 03/29/2018 at 1100 revealed CT Techs were to follow the protocol to determine the amount of contrast to be administered and to set the power injector with NS and the contrast. CT techs were to flush the IV line manually, and if the IV flushed well to follow with the mechanical saline flush. Interview revealed there was no specific amount of saline flush to be done mechanically but the amount should be enough to be able to assess the IV site. Continued interview revealed the average amount should be about 10 cc of NS. The vein could not be fully assessed with using only 2 cc of NS. Further interview revealed staff should use common sense and not push the button for just one second to flush the IV line; it should be pushed long enough to be able to assess the IV line.