HospitalInspections.org

Based on staff interviews, medical record review, incident report review and policy and procedure review it was determined the facility failed to report information necessary to allow tracking of medical errors and adverse patient events for the patient named in the complaint.

Findings include:

For the purpose of this report, the patient named in this investigation will be referred to as Patient #3.

An interview took place on 2/3/11 from 1:20 pm until 2:10 pm with the facility's Intensive Care Unit's (ICU) registered nurse (RN) who was assigned to care for Patient #3 on the day of discharge. The RN stated this hospital's practice is to place all patients requiring detoxification in the ICU for the detoxification process to be completed. The RN stated that it is not uncommon for patients with that diagnosis to remain in the ICU throughout their stay and later discharged from the hospital directly from the ICU. She stated when detoxification is complete and the patient is deemed medically stable, the patient is usually discharged that same day. The patients are commonly discharged to the local Community Service Board (CSB) for prescreening and behavorial health support for treatment of their addiction. The RN stated that 1/5/11 was the first day she had been assigned to provide care to Patient #3; however, she was familiar with the patient's hospital course of care while in the ICU since all ICU nurses listen to report on all patients.

During the interview the RN accessed information regarding Patient #3 from the electronic record in order to refresh her memory. The RN stated she recalled Patient #3 had a history of alcohol abuse, came into the facility's ICU for detoxification, and was requesting help for her alcohol addiction. The RN recalled that on the day of the patient's discharge "she got up, bathed herself and dressed herself." The RN further stated that when the ambulance was ready to transport the patient to the CSB, the patient "walked to the stretcher" without assistance. The RN then stated "I did forget to take one of her IV's (intravenous line) out and the ambulance had to go back over there and take it out." As the RN reviewed the patient's electronic record during the interview, she clarified that the patient had two IV's present for most of her hospital stay, but one had been removed prior to the discharge date. She then confirmed she had inadvertently left the one remaining IV port (heparin lock) in the patient's right upper arm upon discharge. The RN stated she received a phone call from the CSB's "nurse manager" informing her that the patient's IV port had not been removed by the hospital's staff prior to discharge. The RN stated she asked the nurse manager if they (CSB nursing staff) could just take it out and "she said no." The RN stated that the nursing manager told her that someone from the hospital could come to the CSB location to remove it, but they would have to take the patient out of the building and into the parking lot area to do it. The RN stated she then called the ambulance workers that had transported the patient to the CSB earlier to ask them to take her (the nurse) to that location so she could remove the IV port, but they told her they would just go and take it out for her, and to her knowledge, that is what took place. When questioned as to whether she documented this issue with the IV port being left in the patient's arm upon discharge, the RN stated "I think so" but she was unable to provide evidence of that documentation. The RN stated she reported the IV port having been left in the patient's arm upon discharge to her supervisor, the executive director of critical care. The RN included that in her opinion, the patient left the hospital in a medically stable condition.

On 2/3/11 at 2:15 pm the executive director of critical care, who is also a registered nurse was interviewed. She confirmed the RN from ICU had reported to her the incident in which the patient's IV port was left in the patient's arm upon discharge and later found by the staff at the CSB. She further stated, "She thinks," she told the RN to fill out the variance report, but to date does not recall it coming to her for review. The executive director of critical care recalled that about a week after this occurred she received a phone call from "someone at the CSB" but was not sure exactly who called. She stated the CSB employee wanted to make sure she was aware that this incident had occurred. The executive director informed the surveyors she had not reported the incident herself after finding out about it from the nurse or after receiving the phone call from the CSB employee.

An interview took place on 2/3/11 at 3:10 pm with the RN Clinical Risk Analyst. The analyst stated the incident with the IV port (heparin lock) having been inadvertently left in the patient's arm upon discharge should have been reported through their "Riskmaster" program which documents incident reports, variances, and unusual occurrences. The clinical risk analyst stated the Riskmaster program had been live at that hospital since April 2010 and there had been extensive training of staff. She acknowledged there were currently no written policies and procedures in place guiding the process for reporting such events but the hospital was currently working on written policies and procedures for that purpose. However, the risk analyst stated the fact that this employee reported the incident to her supervisor revealed, "she knew it was a diversion from her normal standard of care." The analyst acknowledged the lack of reporting of this variance by both the ICU nurse and her supervisor resulted in a missed opportunity for the hospital to improve performance, "this would be a near miss in our reporting system and would be reviewed in the quality program." She defined a "near miss" as an incident where the patient did not have permanent harm. During the interview with the clinical risk analyst, the incident reports from the timeframe of December 2010 through January 2011 were reviewed. This clinical risk analyst acknowledged the incident in question did not appear in the reports reviewed, and further stated the hospital had no evidence this incident was documented or reported to the quality program.

On 2/3/11 at 5:05 pm the CEO (Chief Executive Officer) was interviewed. This CEO also had a strong background in nursing administration. The CEO acknowledged it would be her expectation that if a patient was discharged with an IV port inadvertently left in place, it would be reported as a variance report with the usual follow up investigation through the quality and risk management program.