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GEISINGER-LEWISTOWN HOSPITAL
PATIENT SAFETY
Tag No.: A0286
Based on facility policy and procedure and staff interview (EMP), it was determined that the facility failed to follow their adopted policy to ensure that managers are investigating and analyzing unusual incidents.
Findings include:
1.) Review of "Geisinger Policy 06.01 Section 6.0 Improving Organizational Performance Title Identification of Events and Patient Safety Reporting" dated January 4, 2016, was conducted. The policy revealed "Purpose: This Patient Safety Reporting procedure establishes guidelines to: ... Establish a reporting system to notify responsible parties about incidents, adverse event or near misses and allow prompt investigation of incidents. ... Responsibilities: Managers are responsible for assisting their staff in their duties under this policy as well as reviewing all reports for appropriate follow-up and process changes in order to prevent future events. ... ."
An interview was conducted on September 15, 2016 at 2:15 PM with EMP12. EMP12 revealed "In reviewing a MIDAS report, you will not see the review of managers. When reviewing the MIDAS reports, I cannot see that a manager has reviewed it, only Danville has that access."