HospitalInspections.org

Based on hospital policy, incident report, root cause analysis review and staff interviews, the hospital staff failed to measure and track strategies for improvement of an adverse patient event for 1 of 1 adverse events reviewed (Patient #16).
The findings include:
Review of the facility's Sentinel Event Policy revised dated of 09/11/2014 revealed "General Policy Statement...it is the policy of (Name of facility) to provide a safe environment for patients, visitors...by responding to occurrences, conducting analysis of the root cause(s) and developing corrective actions that will eliminate or significantly reduce the likelihood of recurrence...f) Quality Improvement is the application of a continuous quality improvement process to objectively and systematically evaluate, monitor, and improve the quality of patient care...g) Corrective Action Plan (CAP) is a written plan developed in response to the completion of a sentinel event review, after a root cause analysis has been completed. The corrective action plan designates the actions to be implemented to resolve, prevent, and/or mitigate the reoccurrence of the event. The plan must designate accountable personnel, time frames for completion and strategies for measuring the effectiveness of actions..."
Closed medical record review of Patient #16 revealed an 18 year old presented to the Emergency Department of the named facility on 11/02/2013 at 1954 with chief complaint of trouble breathing. Review of the record revealed a past medical history of Muscular dystrophy (genetic disease that affects the muscles), seizures, scoliosis, and cardiomyopathy. Continued review revealed the patient was wheelchair dependent and required assistance with ADL's (activities of daily living). Review of the ED Nurse's Notes dated 11/02/2013 at 2016 revealed "Per mother, pt (patient) was seen earlier today for back/kidney issues. Per family, upon d/c (discharge), mother tripped while holding pt and attempting to place in wheelchair. Pt hit head on hard plastic chair. Once home, pt complained of head pain, blurred vision and leg pain. Parents checked pt's pulse and oxygen at home per family was mid-low 80% for oxygen saturation and over 200bpm (beats per minute) for heart rate. Pt states his vision has improved but is still blurry and his leg is in extreme pain 10/10 (pain scoring system, scale of 1 - 10 with 10 being the worse), left knee." Review of the ED Physician Orders dated 11/02/2013 at 2332 revealed an order for left thigh, femur and knee x-ray. Continued review revealed x-rays were taken on 11/02/2013 at 0020. Continued review revealed a final x-ray result (interpretation) date of 12/20/2013 at 0649 (47 days after x-ray was taken). Continued review of the record revealed the patient's respiratory status continued to deteriorate, the patient was intubated (breathing tube) on 11/03/2013 at 0202 while still in the ED then transferred to the Pediatric Intensive Care Unit. Continued review on 11/03/2013 at 0335 revealed a cardiac arrest with cardiopulmonary resuscitation. Continued review revealed the patient expired on 11/03/2013 at 0423.
Review of the Autopsy report dated 11/14/2013 revealed the final autopsy diagnosis was revised on 01/14/2014 following the discovery of radiologic evidence of a fracture of the pubis (pelvis) and femur (upper leg) made available to the medical examiner on 12/19/2013 (46 days after x-ray taken & 35 days after original autopsy). Review of the autopsy report revealed the medical examiner rescinded the original Sepsis (systemic infection) diagnosis as cause of death. Review of the final autopsy report dated 01/14/2014 revealed the revised "...cause of death for this 18 year old...is fat emboli syndrome due to fractures of the pubis and femur."
Review of the RCA dated 04/15/2014 revealed corrective action plan included daily cross referencing and verification that portable x-rays have been uploaded to the PACS (Portable Archiving and Communication System-for x-rays) system.
Interview on 09/24/2013 1116 with the Pediatric Radiology Section Chief and the Chief Technologist revealed on 12/19/2013 they became aware the femur and thigh x-rays for Patient # 16 taken on 11/02/2013 had not been read/interpreted with a final report when the RCA (root cause analysis) committee asked them to retrieve the films for review. Continued interview revealed the x-rays were not read and results reported to the physician when ordered on 11/02/2013 due to technical problems. Continued interview revealed the x-rays were obtained by portable x-ray on 11/02/2013 but was never uploaded to the PACS system therefore the Radiologist did not know there were x-rays to be read/interpreted. Continued interview revealed a corrective action plan implemented with the RCA in April 2014 included a daily end of shift review of the portable x-ray log book in the Pediatric ED to perform a manual cross-reference with the PACS system to ensure the portable x-rays have been uploaded to the PACS system. Continued interview revealed no monitoring of compliance with the cross-referencing since discovering of the error on 12/19/2013 or since implementation of the corrective action plan on 04/15/2014. Continued interview revealed "we currently have no way of knowing if we have missed any other x-rays. We have no monitoring of our action plan." Interview confirmed the hospital staff failed to measure and track strategies for improvement of an adverse patient event for 1 of 1 adverse events reviewed.
Review of the log book dated 08/23/2014 revealed 10 of the 32 portable x-rays had not been checked and cross-referenced to ensure they were uploaded to the PACS system. On 08/25/2014 review revealed 4 of 29 x-rays had not been cross-referenced and verified; on 08/26/2014 review revealed 5 of 25 had not been cross referenced and verified; on 08/27/2014 review revealed 5 of 22 x-rays had not been cross-referenced and verified uploaded to the PACS system. Review of the log book revealed cross-referencing non-compliance with the corrective action plan.
NC00096804, NC00093351, NC00099702, NC00095815, NC00093819, NC00097101, NC00092964, NC00100715