HospitalInspections.org

Based on document review, observation, and interview, it was determined that for 1 of 1 Perioperative Room (OR) suite (#9) observed, the Hospital failed to ensure that opened sterile surgical instruments and equipment were continuously monitored. This failure has the potential to affect 1 patient scheduled for surgery in OR suite #9 on 7/19/18.

Findings include:

1. The Hospital's policy titled, "Sterile Field, Maintaining" (revised 9/1/17), was reviewed on 7/19/18 and required, "2. Continuously monitor all sterile areas for possible contamination."

2. On 7/19/18, between 7:45 AM and 8:30 AM, an observational tour was conducted in the Perioperative Area (OR). At 7:50 AM, sterile surgical instruments and sterile Da Vinci robotic equipment were left open in OR suite #9. No staff were present in OR suite #9 to monitor the sterile instruments. At approximately 7:55 AM, an anesthesiologist (MD#5) entered OR suite #9 and left after approximately 2 minutes. No one else entered OR suite #9 between 7:50 AM to 8:10 AM. At 8:20 AM, there was still no one present in OR suite #9 to monitor the sterile instruments.

3. An interview was conducted with the Director of OR (E#5) on 7/19/18 at 8:30 AM. E#5 stated that a room where sterile surgical instruments are open should be monitored.