HospitalInspections.org

Based on review of hospital documentation and interviews with facility personnel, the facility failed to ensure that adverse events were reported in a timely manner.

The findings include:

1. Patient #1 was admitted to the hospital on 6/19/10 with an unresponsive episode from the dialysis center. Patient #1 was sent to the ICU and an emergency triple lumen catheter was inserted into the right femoral position. On 6/22/10 (3 days later) during an interventional radiology insertion of a hemodialysis catheter, it was identified that a guidewire was left in during the femoral line insertion. The guidewire was removed without any outcome to the patient. Patient #1 expired on 6/23/10 from cardiomyopathy. Further review failed to identify that the adverse event was reported to risk management. Review of hospital policy identified that adverse events are to be reported to immediately to risk management. Interview with the Director of Quality on 11/16/10 identified that the retained foreign body was not reported by the radiology department and was uncovered during the patient's record review by quality improvement.