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Based on review of the Hospital's Internal Investigation regarding a retained triple-lumen catheter guidewire (a guidewire utilized to insert a catheter with 3 passageways into a central vein or artery for diagnostic/therapeutic purposes) incident involving Patient #1 and interviews, it was determined that the Hospital had not developed and implemented a Corrective Action Plan related to the Investigation findings prior to the Survey.

Findings include:

The Hospital reported a retained triple-lumen catheter guidewire incident involving Patient #1. The Report indicated the guidewire was placed in Patient #1's right internal jugular vein by Cardiac Surgery Anesthesia Fellow #1 under the supervision of Attending Cardiac Surgery Anesthesiologist #1 on 10/4/11. On 10/12/11, during a pacemaker insertion, the guidewire was discovered floating in Patient #1's right internal jugular vein/heart. The retained guidewire was successfully removed during the pacemaker insertion procedure. Patient #1 was not harmed by the retained guidewire.

1) Review of the Hospital's Internal Investigation related to Patient #1's retained guidewire on 11/28 and 11/29/11 indicated that Cardiac Surgery Anesthesia Fellow #1 failed to remove the guidewire following the insertion of the triple-lumen catheter.

2) The Department of Anesthesia Physician Director of Quality Assessment (QA)/Quality Improvement (QI) & Safety was interviewed in person on 11/28/11 at 1:30 P.M. The Department of Anesthesia Physician Director of QA/QI & Safety said that Hospital Staff were in the process of developing a Corrective Action Plan related to the Hospital Internal Investigation of Patient #1's retained guidewire incident. The Department of Anesthesia Physician Director of QA/QI & Safety said that corrective actions under consideration for implementation included counting procedures and a procedure checklist.

As of 11/29/11 at 3:30 P.M., the Corrective Action Plan was not developed/implemented.

Based on review of the Hospital's Internal Investigation regarding a retained triple-lumen catheter guidewire (a guidewire utilized to insert a catheter with 3 passageways into a central vein or artery for diagnostic/therapeutic purposes) incident involving Patient #1 and interviews, it was determined that the Hospital had not developed and implemented a Corrective Action Plan related to the Investigation findings prior to the Survey.

Findings include:

The Hospital reported a retained triple-lumen catheter guidewire incident involving Patient #1. The Report indicated the guidewire was placed in Patient #1's right internal jugular vein by Cardiac Surgery Anesthesia Fellow #1 under the supervision of Attending Cardiac Surgery Anesthesiologist #1 on 10/4/11. On 10/12/11, during a pacemaker insertion, the guidewire was discovered floating in Patient #1's right internal jugular vein/heart. The retained guidewire was successfully removed during the pacemaker insertion procedure. Patient #1 was not harmed by the retained guidewire.

1) Review of the Hospital's Internal Investigation related to Patient #1's retained guidewire on 11/28 and 11/29/11 indicated that Cardiac Surgery Anesthesia Fellow #1 failed to remove the guidewire following the insertion of the triple-lumen catheter.

2) The Department of Anesthesia Physician Director of Quality Assessment (QA)/Quality Improvement (QI) & Safety was interviewed in person on 11/28/11 at 1:30 P.M. The Department of Anesthesia Physician Director of QA/QI & Safety said that Hospital Staff were in the process of developing a Corrective Action Plan related to the Hospital Internal Investigation of Patient #1's retained guidewire incident. The Department of Anesthesia Physician Director of QA/QI & Safety said that corrective actions under consideration for implementation included counting procedures and a procedure checklist.

As of 11/29/11 at 3:30 P.M., the Corrective Action Plan was not developed/implemented.