HospitalInspections.org

Based on record review and interview, the facility failed to collect data on equipment failures to enable the facility to monitor the safety of providing their services in 2 of 2 departments (Radiology and Laboratory) in 2 of 2 equipment failures.

Findings include:

Review of policy "Event Reporting" #7528826, last revised 1/18/2020 under purpose/Rationale revealed "appropriate actions... whether they are near misses or have resulted in harm." Intention is to "Reduce events which cause, or have potential to cause, serious harm...Track/trend information and data for analysis and contribution in developing improvement activities." Under Definitions of Events "any happening or occurrence, with or without injury, that is inconsistent with routine operations... Equipment Failures."

On 6/27/2022 at 1:05 PM during interview with Radiology Manager B, Manager B stated Friday night (June 3, 2022) at approximately 11:00 PM the magnetic resonance imaging (MRI) machine had gone down and was out of order until 6/06/2022.

On 6/27/2022 at 1:22 PM during interview with Laboratory Manager F, Manager F stated that on 6/03/2022 from 3:30 AM to 11:00 AM, 2 of 2 of their hematology analyzers were down.

On 6/28/2022 at 4:40 PM during interview with Quality Director of South Region C and Quality Director of North Region E, when asked for safety event/incident reports related to the equipment downtime or equipment failure logs, Director E confirmed there were no incident reports completed or equipment failure logs. Director C stated the equipment issues and processes were discussed with SERT (Safety Event Reporting Team) and confirmed no root cause analysis or other investigations were documented on the hemolytic analyzer or MRI equipment failures.