HospitalInspections.org

Based on record review and interview, the hospital failed to ensure all patient medical records were complete by the person responsible for providing or evaluating the service provided. This deficient practice was evidenced by failure of the hospital to ensure patients' medical records contained documentation that contaminated surgical instruments made it to the sterile field for 3 (#F1, #F3, #F4) of 4 (#F1-#F4) patient records reviewed for contaminated instruments making it to the sterile field during surgery.

Findings:

Patient #F1
Review of the hospital's Safety Event Summary and Follow Up History revealed on 12/16/2019 Patient #F1 was in surgery when a cannulated drill bit was found to be contaminated with bone fragments inside the cannula while the case was in progress.

Review of Patient #F1's medical record with SF4DirSS and SF5NurDir revealed he was admitted on 12/15/2019 and had surgery on 12/16/ 2019 for retrograde femur nail insertion. Further review failed to reveal any documentation of the contaminated cannulated drill bit being discovered with bone fragments during the case.

Patient #F3
Review of the hospital's Safety Event Summary and Follow Up History revealed on 11/20/2019 Patient #F3 was in surgery when a yankeur in the head and neck set which was received from the Sterile Processing Department was contaminated and on the sterile field. The contaminants were found at closing while flushing the lumens. The instrument was immediately removed from the sterile field and the Dr. was notified. The Dr. then stated the patient was going home on antibiotics.

Review of Patient #F3's medical record with SF4DirSS and SF5NurDir revealed he was admitted on 11/20/2019 for outpatient surgery for reconstruction of Patient #F3's left ear. The record failed to reveal any documentation related to the contaminated yankeur being discovered on the sterile field at the closing of the surgery.

Patient #F4
Review of the hospital's Safety Event Summary and Follow Up History revealed on 11/06/2020
Patient #F4 was in surgery and the drill head piece was suspected of being contaminated with rust or blood.

Review of Patient #F4's medical record with SF4DirSS and SF5NurDir revealed he was admitted on 11/6/2019 for outpatient surgery for excision of malignant squamous cells.The record review failed to reveal documentation of the contaminated drill head piece making it to the sterile field.

On 01/15/2020 in an interview SF4DirSS and SF5NurDir verified Patient #F1, #F3 and #F4's medical records failed contain any documentation about the contaminated instruments discovered on the sterile field while the cases were in progress. They also confirmed that the contaminated instruments made it to the sterile field. SF4DirSS and SF5NurDir stated if any instrument is found to be contaminated in a set, the entire set is considered contaminated.