HospitalInspections.org

Based on review of facility documents, medical record review and staff interview (EMP), it was determined that the facility failed to ensure surgery was performed on the correct limb for one of one medical records reviewed (MR1).

Findings include:

Review on March 2, 2011, of the facility's "Intraoperative Nursing Documentation" policy, last reviewed April 17, 2010, revealed "Policy: The Intraoperative Record will be completed for all patients undergoing surgery at the Robert Packer Hospital. The document is a legal record that becomes a part of the patient's permanent medical record. The document is completed by the circulating R.N. The document reflects peri-operative - nursing care that was delivered to the patient. ... 2. Documentation Criteria: Page 1 ... E. Permit signed - check the correct box. F. Designated times are documented: a. Verify with the anesthesia record case start - the time the patients enters to OR. b. surgeon enters - the actual time the surgeon enters the OR ... c. Surgeon exits - the time the surgeon leaves the case. ... d. Incision(s) - the exact time the procedure started ... e. Case end - the time the dressings are applied and the surgical drapes are removed. f. transfer - the time the patient leaves the OR. g. time of Induction - written in by the time of the pause. ... L. The nursing staff section will be completed as follows: a. Inst. Ass't - the senior scrub that is responsible for all the activities that encompass that role. ... M. Enter preoperative diagnosis, post operative diagnosis and operative procedure in spaces provide. ... d. Record operative procedures in the space provided. Operative procedures will be verified with the physician. Right or left laterality must be written out. ..."

Review on March 2, 2011, of the facility's "Universal Protocol Checklist" revealed five areas with a "stop" indicated. Further review of the universal protocol checklist revealed the progression of the checklist included instructions that at the time of admission, preadmission or entry into the facility for the procedure (pre-procedure verification) there was to be verification of the procedure(s): Complete before induction / sedation in procedure room and time out(s): Complete just before incision / start of every procedure in procedural room.

Review on March 2, 2011, of MR1 revealed the patient signed a surgical consent for a right knee arthroscopy (a minimally invasive surgical procedure in which an examination and sometimes treatment of damage of the interior of a joint is performed) to be performed on January 26, 2011.

Review on March 2, 2011, of MR1's "Universal Protocol Checklist" revealed that on January 26, 2011, the facility performed procedure verification on MR1. The procedure verification included verification of the patient (MR1), verification of the correct procedure, confirmation that the correct site was marked with the word right, and the side marked with the initials of the anesthetist and the physician.

Further review of the facility's "Universal Protocol Checklist" for MR1 revealed documentation that the facility performed the time out. The facility documented that they verified the correct person, verified the correct procedure, confirmed the correct site was marked with the word right, and the correct side was marked with initials of the anesthetist and the physician, the correct position of the patient, that an accurate informed consent was obtained, and that the procedure did not move forward until all agreed. The area indicating no discrepancies and all agreed to proceed was checked with a "yes."

Review on March 2, 2011, of MR1's operating room record dated January 26, 2011, revealed that MR1's surgeon dictated an addendum to the operative procedure which included "Postoperatively for this patient, it was discovered in the recovery room once the patient was awake that the patient has had a wrong side surgery performing arthroscopy of the incorrect knee."

Interview with EMP1 on March 2, 2011, at 10:00 AM confirmed that the facility performed a wrong site surgery on MR1.