HospitalInspections.org

Based on interview and record review, the hospital failed to ensure Radiology Personnel provided a safe environment for 1 of 3 patients reviewed [Patient #1]. [Patient #1] received a CT Scan with IV [Intravenous] contrast. Radiology personnel failed to report an extravasation of the contrast media during the procedure to the nurse and/or Radiologist on duty. [Patient #1] was not assessed by the nurse and/or Radiologist and did not receive care in a safe setting. [Patient #1] was sent home from [Hospital #1] after the procedure and developed complications related to the IV [Intravenous] contrast media.

Findings Included:

[Hospital #1's] radiology consultation request dated 01/25/11 reflected, "CT of chest and abdomen with IV contrast..."

[Hospital #1's] Radiology Report dated 03/29/11 timed at 14:05 PM and 13:51 PM reflected, "State school patient...unsuccessful IV access. Oral contrast not administered...non contrasted axial images through the entire abdomen ...at 13:51 PM ...non contrasted thin axial images through the entire chest..." No documentation was found indicating IV dye was injected.

[Hospital #1's] study note/preliminary Report dated 03/29/11 timed at 9:28 AM documented by [Staff #4] reflected, "IV infiltrated, and no other IV access available, done without, reason pain. " No further documentation was found from the Technician indicating type, amount of contrast injected, status of patient and who was notified to assess the patient.

[Hospital #2's] Discharge summary dated 04/17/11 timed at 15:39 PM reflected, "68 year old male undergoing workup for bronchiectasis to have a CT at [Hospital #1]...patient had an IV placed but contrast was extravagated approximately 40 milliliters into arm and axillary portion of chest. Patient had swelling of the arm with blisters upon arriving back to home. Patient was transferred to [Hospital #2] for evaluation. Seen by trauma service who took patient for compartment syndrome fasciotomy...tolerated...seen by pulmonary services...patient returned to surgery for closure of his fasciotomy and in stable condition...discharged home 04/06/11..."

[Hospital #2's] physician assessment dated 03/29/11 timed at 15:11 PM reflected, "Patient arrived by ambulance. Patient seen outside hospital for CT of chest. Received IV contrast via IV in the right hand. After returning home experienced swelling in his right arm...patient is experiencing moderate pain...severe contractures in all extremities especially the upper extremities. Right arm is markedly swollen three fourths of the way up ending about mid/upper humerus...unable to palpate a pulse in arm because of soft tissue swelling but capillary refill is good. Evidence of prior IV start site in right hand...exams right humerus findings...contrast extravasation, extends into the distal aspect of the upper arm...right forearm...extensive soft tissue infiltration of contrast both anterior and posterior...right hand findings....dense contrast extravasation along dorsum of hand extending into wrist...extensive extravasation of contrast ..."

[Hospital #2's] physician progress and procedure note dated 03/29/11 timed at 20:13 PM reflected, "16:00 PM contacted [Hospital #1] stated technician reported patient experienced approximately 40 milliliters high pressure extravasation into right hand during CT Scan ....physician agrees to consult as patient is at high risk based on x-rays that shows a large degree of extravasation, we suspect greater than 40 milliliters...for compartment syndrome ...17:30 PM patient to go to OR [Operating Room]...clinical impression IV contrast extravasation right upper extremity, swelling right upper extremity, and compartment syndrome ..."

On 05/19/11 at 11:55 AM Staff #2 was interviewed. Staff #2 stated the Emergency Room physician from [Hospital #2] called him regarding [Patient #1]coming in with an extravasation from the IV contrast media earlier administered at [Hospital #1] on 03/29/11. Staff #2 stated he spoke with the CT Technician and the technician reported the IV infiltrated and 40 ml of contrast media was extravasated. Staff #2 stated the technician did not follow the procedure for extravasation. He stated the technician did not notify the nurse and/or the Radiologist on duty to assess the patient after the extravasation.

On 05/19/11 at 1:00 PM, Staff #4 was interviewed. Staff #4 was asked what the hospital policy was when extravasation occurs. Staff #4 stated he was supposed to notify the nurse on duty and/or the Radiologist. Staff #4 was asked if he notified the nurse and/or the Radiologist. He stated "No, he thought it was just a small extravasation and they were busy. He stated no contrast media was on the scan. Staff #4 stated he told the individual who was with the patient to apply warm compresses to the site.

On 05/20/11 at 2:54 PM Staff #3 was interviewed. Staff #3 stated she reviewed [Patient #1's] medical record. The surveyor asked Staff #3 if she was aware [Patient#1] sustained an extravasation after contrast media was administered 03/29/11 during [Patient #1's] visit to [Hospital #1]. She stated, "No." She stated no one told her or she would have looked at the patient. Staff #3 stated she was unaware [Patient #1] had complications related to the extravasation. She stated the technician never said anything to her. Staff #3 stated the technician should have reported it so she could have assessed the patient.

[Hospital #1's] policy entitled, "Patient Rights and Responsibilities" with a revision date of 01/2009 reflected, "It is responsibility of all hospital staff to know and support patient's rights...to provide care and interaction and to support these rights and responsibilities...reasonable continuity of care...the right to appropriate assessment and management of pain..."

Based on interview and record review, the hospital failed to ensure 1 of 3 patients [Patient #1] who received a CT Scan with IV [Intravenous] contrast dye was provided an environment free from hazards. Radiology personnel failed to report an extravasation for 1 of 3 patient's [Patient #1]. The hospital further failed to follow hospital policy and procedures designed to protect the patient.

Findings Included:

[Hospital #1's] radiology consultation request dated 01/25/11 reflected, "CT of chest and abdomen with IV contrast..."

[Hospital #1's] Radiology Report dated 03/29/11 timed at 14:05 PM and 13:51 PM reflected, "State school patient...unsuccessful IV access. Oral contrast not administered...non contrasted axial images through the entire abdomen ...at 13:51 PM ...non contrasted thin axial images through the entire chest..." No documentation was found indicating IV dye was injected.

[Hospital #1's] study note/preliminary report dated 03/29/11 timed at 9:28 AM documented by [Staff #4] reflected, "IV infiltrated, and no other IV access available, done without, reason pain. " No further documentation was found from the Technician indicating type, amount of contrast injected, status of patient and who was notified to assess the patient.

[Hospital #2's] Discharge summary dated 04/17/11 timed at 15:39 PM reflected, "68 year old male undergoing workup for bronchiectasis to have a CT at [Hospital #1]...patient had an IV placed but contrast was extravagated approximately 40 milliliters into arm and axillary portion of chest. Patient had swelling of the arm with blisters upon arriving back to home. Patient was transferred to [Hospital #2] for evaluation. Seen by trauma service who took patient for compartment syndrome fasciotomy...tolerated...seen by pulmonary services...patient returned to surgery for closure of his fasciotomy and in stable condition...discharged home 04/06/11..."

[Hospital #2's] physician assessment dated 03/29/11 timed at 15:11 PM reflected, "Patient arrived by ambulance. Patient seen outside hospital for CT of chest. Received IV contrast via IV in the right hand. After returning home experienced swelling in his right arm...patient is experiencing moderate pain...severe contractures in all extremities especially the upper extremities. Right arm is markedly swollen three fourths of the way up ending about mid/upper humerus...unable to palpate a pulse in arm because of soft tissue swelling but capillary refill is good. Evidence of prior IV start site in right hand...exams right humerus findings...contrast extravasation, extends into the distal aspect of the upper arm...right forearm...extensive soft tissue infiltration of contrast both anterior and posterior...right hand findings....dense contrast extravasation along dorsum of hand extending into wrist...extensive extravasation of contrast ..."

[Hospital #2's] physician progress and procedure note dated 03/29/11 timed at 20:13 PM reflected, "16:00 PM contacted [Hospital #1] stated technician reported patient experienced approximately 40 milliliters high pressure extravasation into right hand during CT Scan ....physician agrees to consult as patient is at high risk based on x-rays that shows a large degree of extravasation, we suspect greater than 40 milliliters...for compartment syndrome ...17:30 PM patient to go to OR [Operating Room]...clinical impression IV contrast extravasation right upper extremity, swelling right upper extremity, and compartment syndrome ..."

On 05/19/11 at 11:55 AM Staff #2 was interviewed. Staff #2 stated the Emergency Room physician from [Hospital #2] called him regarding [Patient #1] coming in with an extravasation from the IV contrast media earlier administered at [Hospital #1] on 03/29/11. Staff #2 stated he spoke with the CT Technician and the technician reported the IV infiltrated and 40 ml of contrast media was extravasated. Staff #2 stated the technician did not follow the procedure for extravasation. He stated the technician did not notify the nurse and/or the Radiologist on duty to assess the patient after the extravasation.

On 05/19/11 at 1:00 PM, Staff #4 was interviewed. Staff #4 was asked what the hospital policy was when extravasation occurs. Staff #4 stated he was supposed to notify the nurse on duty and/or the Radiologist. Staff #4 was asked if he notified the nurse and/or the Radiologist. He stated "No, he thought it was just a small extravasation and they were busy. He stated no contrast media was on the scan. Staff #4 stated he told the individual who was with the patient to apply warm compresses to the site.

On 05/20/11 at 2:54 PM Staff #3 was interviewed. Staff #3 stated she reviewed [Patient #1's] medical record. The surveyor asked Staff #3 if she was aware [Patient#1] sustained an extravasation after contrast media was administered 03/29/11 during [Patient #1's] visit to [Hospital #1]. She stated, "No." She stated no one told her or she would have looked at the patient. Staff #3 stated she was unaware [Patient #1] had complications related to the extravasation. She stated the technician never said anything to her. Staff #3 stated the technician should have reported it so she could have assessed the patient.

The Policy and Procedure: entitled "Intravenous Contrast Administration in Medical Imaging" undated reflected, under the section entitled, "Extravasation Guidelines" reflected, "Extravasation of contrast media is toxic to the surrounding tissues, particularly the skin and can produce an acute inflammatory response. Ulceration and necrosis may result and can be identified as early as six hours after the injury. Compartment syndrome may occur if enough contrast material is extravasated...when extravasation occurs, notify the radiologist or department nurse. If radiologist not available, notify the ED physician and/or primary care physician. The radiology technologist or department nurse will document the location of the extravasation, the type and amount of contrast, the appearance of the site as well as the patient 's symptoms...immediate treatment for contrast extravasation includes elevation of the affected extremity and application of warm compresses. In most cases the patient ' s body will absorb the contrast without any negative sequale...surgical consult may be indicated under the direction of the radiologist or primary care physician. The American College of Radiology recommends an immediate surgical consult for...increased swelling or pain after 2 to 4 hours, altered tissue perfusion as evidenced by decreased capillary refill at any time after extravasation has occurred, change in sensation in the affected limb and skin ulceration or blistering..."

The Hospital policy entitled, "Operating of Medical Imaging Equipment" with a revision date of 06/02/06 reflected, "All radiation-producing equipment controlled by Medical Imaging services shall be used under the direction of the radiologist and by trained, licensed radiologic technologists..."

Based on interview and record review, the hospital failed to ensure the Radiologist on duty supervised the ionizing radiology services provided for 1 of 3 patients [Patient #1] who received an IV with contrast dye for the chest and abdomen. The Radiologist on duty was not aware an extravasation had occurred causing the IV dye to disperse into the surrounding tissue of the right hand and arm which resulted in [Patient #1] emergently transferred to a secondary hospital [Hospital #2]. This failure resulted in [Patient #1] having to undergo draining of the IV dye and an fasciotomy of the right hand and arm.

Findings Included:

[Hospital #1's] radiology consultation request dated 01/25/11 reflected, "CT of chest and abdomen with IV contrast..."

[Hospital #1's] Radiology Report dated 03/29/11 timed at 14:05 PM and 13:51 PM reflected, "State school patient...unsuccessful IV access. Oral contrast not administered...non contrasted axial images through the entire abdomen ...at 13:51 PM ...non contrasted thin axial images through the entire chest..." No documentation was found indicating IV dye was injected

[Hospital #1's] study note/preliminary report dated 03/29/11 timed at 9:28 AM documented by [Staff #4] reflected, "IV infiltrated, and no other IV access available, done without, reason pain. " No further documentation was found from the Technician indicating type, amount of contrast injected, status of patient and who was notified to assess the patient.

[Hospital #2's] Discharge summary dated 04/17/11 timed at 15:39 PM reflected, "68 year old male undergoing workup for bronchiectasis to have a CT at [Hospital #1]...patient had an IV placed but contrast was extravagated approximately 40 milliliters into arm and axillary portion of chest. Patient had swelling of the arm with blisters upon arriving back to home. Patient was transferred to [Hospital #2] for evaluation. Seen by trauma service who took patient for compartment syndrome fasciotomy...tolerated...seen by pulmonary services...patient returned to surgery for closure of his fasciotomy and in stable condition...discharged home 04/06/11..."

[Hospital #2's] physician assessment dated 03/29/11 timed at 15:11 PM reflected, "Patient arrived by ambulance. Patient seen outside hospital for CT of chest. Received IV contrast via IV in the right hand. After returning home experienced swelling in his right arm...patient is experiencing moderate pain...severe contractures in all extremities especially the upper extremities. Right arm is markedly swollen three fourths of the way up ending about mid/upper humerus...unable to palpate a pulse in arm because of soft tissue swelling but capillary refill is good. Evidence of prior IV start site in right hand...exams right humerus findings...contrast extravasation, extends into the distal aspect of the upper arm...right forearm...extensive soft tissue infiltration of contrast both anterior and posterior...right hand findings....dense contrast extravasation along dorsum of hand extending into wrist...extensive extravasation of contrast ..."

[Hospital #2's] physician progress and procedure note dated 03/29/11 timed at 20:13 PM reflected, "16:00 PM contacted [Hospital #1] stated technician reported patient experienced approximately 40 milliliters high pressure extravasation into right hand during CT Scan ....physician agrees to consult as patient is at high risk based on x-rays that shows a large degree of extravasation, we suspect greater than 40 milliliters...for compartment syndrome ...17:30 PM patient to go to OR [Operating Room]...clinical impression IV contrast extravasation right upper extremity, swelling right upper extremity, and compartment syndrome ..."

On 05/19/11 at 11:55 AM Staff #2 was interviewed. Staff #2 stated the Emergency Room physician from [Hospital #2] called him regarding [Patient #1] coming in with an extravasation from the IV contrast media earlier administered at [Hospital #1] on 03/29/11. Staff #2 stated he spoke with the CT Technician and the technician reported the IV infiltrated and 40 ml of contrast media was extravasated. Staff #2 stated the technician did not follow the procedure for extravasation. He stated the technician did not notify the nurse and/or the Radiologist on duty to assess the patient after the extravasation.

On 05/19/11 at 1:00 PM, Staff #4 was interviewed. Staff #4 was asked what the hospital policy was when extravasation occurs. Staff #4 stated he was supposed to notify the nurse on duty and/or the Radiologist. Staff #4 was asked if he notified the nurse and/or the Radiologist. He stated "No, he thought it was just a small extravasation and they were busy. He stated no contrast media was on the scan. Staff #4 stated he told the individual who was with the patient to apply warm compresses to the site.

On 05/20/11 at 2:54 PM Staff #3 was interviewed. Staff #3 stated she reviewed [Patient #1's] medical record. The surveyor asked Staff #3 if she was aware [Patient#1] sustained an extravasation after contrast media was administered 03/29/11 during [Patient #1's] visit to [Hospital #1]. She stated, "No." She stated no one told her or she would have looked at the patient. Staff #3 stated she was unaware [Patient #1] had complications related to the extravasation. She stated the technician never said anything to her. Staff #3 stated the technician should have reported it so she could have assessed the patient.

The Policy and Procedure: entitled, "Intravenous Contrast Administration in Medical Imaging" undated reflected, under the section entitled, "Extravasation Guidelines" reflected, "Extravasation of contrast media is toxic to the surrounding tissues, particularly the skin and can produce an acute inflammatory response. Ulceration and necrosis may result and can be identified as early as six hours after the injury. Compartment syndrome may occur if enough contrast material is extravasated ...when extravasation occurs, notify the radiologist or department nurse. If radiologist not available, notify the ED physician and/or primary care physician. The radiology technologist or department nurse will document the location of the extravasation, the type and amount of contrast, the appearance of the site as well as the patient 's symptoms...immediate treatment for contrast extravasation includes elevation of the affected extremity and application of warm compresses. In most cases the patient ' s body will absorb the contrast without any negative sequale...surgical consult may be indicated under the direction of the radiologist or primary care physician. The American College of Radiology recommends an immediate surgical consult for...increased swelling or pain after 2 to 4 hours, altered tissue perfusion as evidenced by decreased capillary refill at any time after extravasation has occurred, change in sensation in the affected limb and skin ulceration or blistering..."

The Hospital policy entitled, "Operating of Medical Imaging Equipment" with a revision date of 06/02/06 reflected, "All radiation-producing equipment controlled by Medical Imaging services shall be used under the direction of the radiologist and by trained, licensed radiologic technologists..."