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OHIO STATE UNIVERSITY HOSPITALS
OPERATING ROOM POLICIES
Tag No.: A0951
Based on personnel file review, staff interview, and policy review it was determined the facility failed to ensure all staff were trained on malignant hyperthermia where general anesthesia is administered. This has the potential to affect all patients receiving surgical services. The active census was 831.
Findings include:
Review of the Policy and Procedure Peri-Op- Malignant Hyperthermia states malignant hyperthermia is a rare but life threatening complication that may be triggered by medications commonly used for general anesthesia. Once the diagnosis of malignant hyperthermia is determine/suspected, immediate treatment should occur. Necessary equipment includes a malignant hyperthermia box with associated supplies that will be available all all times for the patient in the peri-operative area. All staff should be familiar with the treatment protocol and contents of the malignant hyperthermia cart or box. The policy failed to include a malignant hyperthermia kit/cart will be stored in the bronchoscopy lab where general anesthesia is administered.
Review of the University Hospital Perioperative 2020 annual training included malignant hyperthermia with a learning objective of being able to calculate the correct dose for the initial Dantrolene. Learner will also verbalize who they need to call and the information needed.
1. An interview was conducted with Staff I on 11/03/20 at 4:09 PM who reported being unsure if the bronchoscopy lab had a malignant hyperthermia kit and could not recall receiving training as per policy. Review of the personnel file lacked evidence of the annual training for malignant hyperthermia. Staff D confirmed this finding during a teams meeting on 11/04/20 at 12:32 PM.
2. Following the personnel file review a request was made for the number of staff working the bronchoscopy lab where general anesthesia is administered. Staff C confirmed on 11/04/20 at 1:36 PM of the nineteen employees in the bronchoscopy lab eight staff members could not recall receiving malignant hyperthermia training.