HospitalInspections.org

Based on record review and staff interview, the hospital failed to fully examine the credentials of the two orthopedic surgeons by allowing them to perform services for which they do not hold privileges at the hospital. This practice allowed unqualified doctors to read and interpret x-rays of their patients. The findings are:

A. Review of the two orthopedic surgeons' credentialing files revealed a list of privileges that they could choose to hold at the hospital. The list did not include examining x-rays.

B. On 05/22/13 at 12:00 pm, during an interview, the Radiology Supervisor stated the two orthopedic surgeons did read and interpret their own x-rays.

C. On 05/22/13 at 3:15 pm, during an interview, the Medical Staff Coordinator confirmed there was nothing in the orthopedic surgeons' credentialing files to show that they had the privilege to read and interpret x-rays.

Based on record review and staff interview, the hospital failed to ensure that a qualified radiologist read and interpreted the x-rays for orthopedic patients seen at the hospital's outpatient clinic for 3 of 4 sampled orthopedic patients (#8, 10, and 11). The hospital further failed to ensure that the medical staff specified what radiological tests had to be read and interpreted by a qualified radiologist. This failed practice could lead to x-rays being misinterpreted and possible problems being missed. The findings are:

A. Review of Patient #8's clinical record revealed an x-ray dated 03/15/13 for a right hip fracture. This x-ray was read and interpreted by Orthopedic Surgeon #1. The x-ray was not interpreted by another doctor.

B. Review of Patient #10's clinical record revealed an x-ray dated 03/04/13 of the right wrist. This x-ray was read and interpreted by Orthopedic Surgeon #2. The x-ray was not interpreted by another doctor.

C. Review of Patient #11's clinical record revealed an x-ray dated 03/18/13 of the left hip. This x-ray was read and interpreted by Orthopedic Surgeon #1. The x-ray was not interpreted by another doctor.

D. On 05/23/13 at 9:30 am, during an interview, the Operations/Quality Director confirmed no radiologist read and interpreted the x-rays for these patients.

E. Review of the Medical Staff By-Laws (reviewed by the hospital 01/23/13) and Medical Staff policies and procedures revealed nothing written to specify what radiological tests require a qualified radiologist's specialized knowledge to read and interpret.

F. On 05/22/13 at 3:15 pm, during an interview, the Medical Staff Coordinator confirmed the that Medical Staff By-Laws and policies and procedures did not specify what radiological tests require a qualified radiologist's specialized knowledge to read and interpret.

G. On 05/23/13 at 9:30 am, during an interview, the Operations/Quality Director confirmed the that hospital did not have anything written to specify what radiological tests require a qualified radiologist's specialized knowledge to read and interpret.