HospitalInspections.org

Based on medical record review and staff interview, it was determined the facility failed to ensure a system was in place to identify a catheter dislocation for Patient #1. The sample size was five (5). The facility census was 291.

Findings include:

The radiologist identified the catheter dislocation in the narrative section of the x-ray report but did not put this finding in the final impression section of the report. The findings were noted as "there is a right sided internal jugular port in place with the tip positioned in the high inferior vena cava." The proper location for the tip to be positioned was the superior vena cava.

The oncologist failed to review the x-ray report in its entirety which included the narrative section and the final impression section.

Please refer to A-347 for specific details.

Based on medical record review and staff interview, it was determined the facility failed to ensure the medical staff provided care (reviewed x-ray films in a complete manner) to ensure an implanted port catheter was positioned in the appropriate/intended vessel for Patient #1. The sample size was five (5). The facility census was 291.

Findings include:

Review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 10/20/11 with a diagnosis of hepatoblastoma (cancer of the liver). On 10/28/11 the medical record had documentation the patient was taken to the operating room where a double lumen port indwelling catheter was placed in the right subclavian vessel. The record documents the patient underwent chemotherapy per the central port catheter on 10/29/11 and 10/30/11. The patient was discharged home on 10/31/11.

On 11/01/11 the patient was readmitted to hospital with diagnosis of mouth pain and inflammation of the mouth. The patient remained in the hospital until 11/21/11 when transferred to another inpatient facility.

On 11/10/11 a chest film was done with contrast media (dye). The chest film report, dictated 11/10/11 at 5:07 P.M., stated in the findings paragraph, "there is a right sided internal jugular port in place with the tip positioned in the high inferior vena cava." The proper location for the tip to be positioned was the superior vena cava.

Interview with Staff A on 12/21/11 at 3:30 P.M. revealed the oncology team had "missed" the findings on the chest film that the port catheter was positioned in the inferior vena cava and not in the superior vena cava as it was supposed to be. Staff A stated the port catheter had become dislodged ("slipped") in the last three weeks. The documentation reveals the port was inserted on 10/28/11 and had become dislodged sometime between the initial placement and when the xray was completed on 11/10/11.

Staff A further stated the oncology team had not became aware of the displacement of the port catheter until after Patient #1 was transferred to another hospital on 11/21/11. Staff A stated the radiologist had picked up on the placement (tip termination) of the catheter in the inferior vena cava (instead of the superior vena cava) but failed to dictate this finding in the final impression. Staff A was not sure how the finding was missed by the oncology team. Staff A stated as of 12/21/11 no systematic changes or corrective measures had been implemented as the occurrence was in the investigation process. Staff A stated they felt corrective measures would be developed and implemented at the conclusion of the root cause analysis that was currently in process.

This substantiates complaint OH00063646.