HospitalInspections.org

Based on medical record reviews, policy reviews and staff interviews, it was determined the facility failed to ensure that radiological services were provided in a safe manner. Specifically, the facility's staff failed to safely administer a contrast medium (a chemical substance used to enhance the display contrast of structures or fluids within the body in medical imaging - commonly used to enhance the visibility of blood vessels and the gastrointestinal tract) in 1 of 11 sampled medical records reviewed. This was found for patient #1 (MR#1).


Findings included:

A review of medical record #1 on February 4, 2015 revealed this forty-nine year old patient was admitted to the facility on May 14, 2014 for shortness of breath, difficulty swallowing and pain and redness in the right eye. The patient had a previous medical history of Asthma. Upon admission the patient was alert and oriented to person, place and time, and she was not in acute distress.

On May 14, 2014, during the administration of a contrast dye, patient #1 sustained an extravasation [the accidental administration of intravenously (IV) infused medications into the extravascular space/tissue around infusion sites] of the contrast medium in the dorsum (back) of her dominant (left) hand. On May 14, 2014 at 3:30 PM a fasciotomy (a surgical procedure where the fascia - connective tissue fibers, primarily collagen, that form sheets or bands beneath the skin to attach, stabilize, enclose, and separate muscles and other internal organs - is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle) was initiated in the operating room (OR). The procedure entailed 2 wounds and the insertion of a vacuum pump at the operative site to address the Compartment Syndrome (increased pressure within one of the body's compartments which contains muscles and nerves) she had developed in the hand. During the procedure a large blood clot was removed.

Staff #1, the Assistant Vice President of the Hospital, was interviewed on February 4, 2014 at 12:30 PM. Staff #1 stated that at 8:41 AM on May 14, 2014, a radiology technician began the administration of Opitray 300, a contrast dye into the patent's access by way of a power injector. The procedure was immediately terminated when the patient complained of pain at the infusion site, which was approximately 1 minute after the infusion began. Staff #1 further stated that the patient sustained an extravasation of the fluid into the dorsum of the patient's left hand as evidenced by 3+ swelling which extended up to her forearm.

A review of the facility's policy titled "Injection of IV Contrast Materials" which was last revised 2/13, revealed the purpose of procedure is "to insure IV contrast material is administered safely."

On May 17, 2014 the patient was taken to the radiology department for a computerized axial topography (CT-Scan) of her chest. At 5:19 AM that day, a nurse documented that the patient received Morphine via a 22 gauge angio-catheter which was a new access.

The patient also returned to the OR on June 10, 2014 for an opened fasciotomy of the wounds.