HospitalInspections.org

Based on observation and staff interview it was determined the facility failed to ensure supplies were stored in a manner that promoted staff and patient safety in 1 of 1 OR suites where a surgical procedure was observed. Failure to ensure supplies were stored appropriately had the potential to compromise patient and staff safety in the event of an emergency evacuation. Findings include:

1. A portion of one surgical procedure was observed in OR #4, from 9:40 AM to 10:10 AM on 2/17/11. The room was small and crowded. Equipment utilized during the surgery included the table containing sterile equipment, the ventilator and anesthesia carts, the gurney, an IV pole for the patient, a tower with a light source, a cautery unit, a computer for charting, an IV pole for irrigation fluid, and a C-arm for x-rays. The room also contained at least 2 small swivel stools, mounted computer screens with keyboards, a large metal wired cart containing a medication distribution module, and three supply carts of various sizes. Supply closets were built into two walls of the OR and were not easily accessible as a result of equipment placed in front of the doors. The five individuals involved in the surgery (the Surgeon, the Anesthetist, the Scrub Technician, the Circulating Nurse, and a Radiology Technician) had to carefully maneuver around objects to maintain the sterile field and complete their tasks.

A tour of the entire Surgical Department was conducted with the Director of Peri-operative Services on 2/17/11 from 1:30 PM to 2:00 PM. The Director explained OR #4 was the smallest room at 350 square feet and was primarily used for clean procedures, such as cystoscopies. However, if needed in a trauma emergency, the extra equipment in the room would be removed to allow more space. She verified the room was very crowded at times and staff and patient safety was a concern.

2. The hallways in the Surgical Department were lined on both sides with equipment. One side of one hallway contained scrub sinks for hand washing use prior to surgery. Directly across from the sinks were several carts containing sterile supplies for surgeries. Additional sterile-wrapped containers were stacked on top of the carts. Further down this hallway were additional storage carts (for non-sterile items) a coat rack and a gurney. A second hallway was lined on both sides with storage carts, a linen cart, a C-arm, short stools, large wheeled poles with monitors mounted on top, and at least two other large pieces of equipment. The remaining hallway space was narrow enough to restrict the movement of patients with any necessary life-supporting equipment, who required emergent evacuation.

In addition, use of hallway space for excessive storage indicated a lack of organized supply and storage. The potential to block access to emergency equipment, alarms, and electrical control equipment existed. As a result of the amount of storage in place, if one piece of equipment required movement to access something (such as a fire extinguisher), the relocated piece of equipment had the potential to cause additional blockage of hallway space.

During the tour of the Surgical Department on 2/17/11 at 1:40 PM, the Director of Peri-Operative Services agreed the hallways were crowded and stated there was no alternative for storage. She stated as a result of the lack of proper storage room, certain doors were dedicated to being blocked by equipment in the hallway and were no longer used. She stated the clutter had a potential to pose a problem in the case of an evacuation and equipment would likely have to be moved to assist in an emergency.

The Surgeon involved in the surgery described above in OR #4 on 2/17/11 at 9:40 AM was interviewed on 2/17/11 at 4:20 PM. He stated OR #4 was often crowded with equipment and personnel during procedures. He stated the impact of the smaller room was a small table had to be used for sterile equipment. He stated the Scrub Technician had to be careful to not place an object on the fragile and expensive equipment used during the surgery.

The Chief of Anesthesiology was interviewed on 2/18/11 at 8:20 AM. He stated the overcrowding of supplies and equipment in the Surgical Department was a problem. However, he stated this was a problem he has seen in other OR suites he has worked in.

The Director of Environmental Services was interviewed on 2/18/11 at 8:35 AM. He stated the storage of supplies and equipment was currently being addressed. He stated the hospital was evaluating alternative ways to manage the problem.

The facility failed to ensure supplies in the OR suite were stored in a manner to promote staff and patient safety.