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TEXAS HEALTH HARRIS METHODIST HURST-EULESS-BEDFORD 1600 HOSPITAL PARKWAY BEDFORD, TX 76022 March 21, 2012
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interviews and record review, the hospital failed to provide care in a safe environment for 1 of 1 patient (Patient #1) whose blood specimen was processed under a different patient name (Patient #2) raising concerns regarding Patient #1 having a heart attack.

Findings included:

Patient #1's medical record reflected she was admitted to the hospital's main ED on 02/01/12 at 8:27 PM. An order was written on 02/01/12 at 8:40 PM for a blood sample to be drawn for tests including cardiac enzymes. The diagnosis documentation dated 02/02/12 at 12:21 AM reflected an "elevation of cardiac enzymes - could be a lab error." The discharge summary dated 02/03/12 at 12:32 PM reflected patient #1's "initial cardiac enzymes drawn in the ER were elevated but this was later thought to be a lab error."

Patient #2's medical record reflected he was admitted to the Hospital's ED on 01/18/12 at 12:37 PM with a diagnoses of Coumadin toxicity and chest pain.

During an interview on 03/20/12 at 12:40 PM Hospital Personnel #3 stated that the process of printing out a patient label and computerized lab requisition "did not happen in this case [Patient #1] and the lab person printed out a requisition with the wrong patient name."

Hospital Personnel #8 stated during an interview on 03/20/12 at 1:20 PM that if a patient specimen came to the lab without a requisition sticker, lab personnel would go into the system and pick the patient and physician order. For Patient #1 "they picked the wrong patient."

Hospital Personnel #1 was asked during an interview on 03/21/12 at 10:45 AM whether she was aware of hospital policy requiring staff to place the lab requisition sticker on the specimen tube before sending it to the lab to be processed; she stated "no."

Hospital Personnel #8 was interviewed again on 03/21/12 at 2:40 PM and stated the "sample was collected on the wrong patient unless there was an extra tube [of specimen]."

Review of the Hospital Policy Nursing 03-003 dated 09/10 reflected the expectation to "obtain the lab generated bar code label and verify test and times with the physician orders...collect the ordered specimen...and attach barcode label...to the specimen tubes."
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on interviews and record review, the hospital failed to set priorities for it's performance improvement activities in that it did not focus on problem prone areas. The hospital had 239 incidents of specimen labeling errors within 14 months including 1 of 1 patient (Patient #1) whose blood specimen was processed by lab services under a different patient name (Patient #2) raising concerns regarding Patient # 1 having a heart attack.

Findings included:

Patient #1's medical record reflected she was admitted to the hospital's main ED on 02/01/12 at 8:27 PM. An order was written on 02/01/12 at 8:40 PM for a blood sample to be drawn for tests including cardiac enzymes. The diagnosis documentation dated 02/02/12 at 12:21 AM reflected an "elevation of cardiac enzymes - could be a lab error." The discharge summary dated 02/03/12 at 12:32 PM reflected patient #1's "initial cardiac enzymes drawn in the ER were elevated but this was later thought to be a lab error."

Patient #2's medical record reflected he was admitted to the Hospital's ED on 01/18/12 at 12:37 PM with a diagnoses of Coumadin toxicity and chest pain.

During an interview on 03/20/12 at 12:40 PM Hospital Personnel #3 stated that the process of printing out a patient label and computerized lab requisition "did not happen in this case [Patient #1] and the lab person printed out a requisition with the wrong patient name."

During an interview on 03/20/12 at approximately 12:50 PM Hospital Personnel #3 stated the hospital had 45 incidents of "labeling errors" in January and February 2012, due to "requisition [sheets] not being sent with specimens" by nurses. Hospital Personnel #3 stated a total of 194 incidents of "specimen labeling errors" were reported in 2011.

Hospital Personnel #8 stated during an interview on 03/20/12 at 1:20 PM that if a patient specimen came to the lab without a requisition sticker, lab personnel would go into the system and pick the patient and physician order. For Patient #1 "they picked the wrong patient."

Hospital Personnel #10 stated during an interview on 03/21/12 at 9:15 AM the lab processed an ICU patient's blood with ED Patient #1's identifying information. Hospital Personnel #10 stated lab technicians "sometimes" called the ED and told staff they "had blood and no orders."

During an interview on 03/21/12 at 12:40 PM Hospital Personnel #12 stated the hospital had identified the problem of mislabeled specimen a year ago but "process improvement measures were not implemented" such as the use of the portable sample collection and label printing device.

Quality Assurance documentation reflected a 53 percent increase in specimen labeling errors in January and February 2012 compared to the same time in 2011.

The Hospital Policy Nursing 03-003 dated 09/10 reflected the expectation to "obtain the lab generated bar code label and verify test and times with the physician orders...collect the ordered specimen...and attach barcode label...to the specimen tubes."
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
The Hospital failed to provide a well-organized nursing service in the hospital's main Emergency Department (ED) for 1 out of 1 patient (Patient #1) whose blood specimen was collected by nursing personnel in the ED for lab processing. The specimen was not labeled per hospital policy which resulted in the lab processing Patient #1's blood specimen under a different patient's name (Patient #2).

Findings included:

Patient #1's medical record reflected she was admitted to the hospital's main ED on 02/01/12 at 8:27 PM. An order was written on 02/01/12 at 8:40 PM for a blood sample to be drawn for tests including cardiac enzymes. The diagnosis documentation dated 02/02/12 at 12:21 AM reflected an "elevation of cardiac enzymes - could be a lab error." The discharge summary dated 02/03/12 at 12:32 PM reflected patient #1's "initial cardiac enzymes drawn in the ER were elevated but this was later thought to be a lab error."

Patient #2's medical record reflected he was admitted to the Hospital's ED on 01/18/12 at 12:37 PM with a diagnoses of Coumadin toxicity and chest pain.

During an interview on 03/20/12 at 12:40 PM Hospital Personnel #3 stated that the process of printing out a patient label and computerized lab requisition "did not happen in this case [Patient #1] and the lab person printed out a requisition with the wrong patient name."

Hospital Personnel #8 stated during an interview on 03/20/12 at 1:20 PM that if a patient specimen came to the lab without a requisition sticker, lab personnel would go into the system and pick the patient and physician order. For Patient #1 "they picked the wrong patient."

Hospital Personnel #10 stated during an interview on 03/21/12 at 9:15 AM the lab processed an ICU patient's blood with ED Patient #1's identifying information. Hospital Personnel #10 stated lab technicians "sometimes" called the ED and told staff they "had blood and no orders."

Hospital Personnel #1 was asked during an interview on 03/21/12 at 10:45 AM whether she was aware of hospital policy requiring staff to place the lab requisition sticker on the specimen tube before sending it to the lab to be processed; she stated "no."

Review of the Hospital Policy Nursing 03-003 dated 09/10 reflected the expectation to "obtain the lab generated bar code label and verify test and times with the physician orders...collect the ordered specimen...and attach barcode label...to the specimen tubes."
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
Based on interviews and record review, the hospital failed to integrate its Emergency Department services with other departments of the hospital for 1 of 1 patient (Patient #1) whose blood specimen was processed by laboratory (lab) services under a different patient name (Patient #2) raising concerns regarding Patient # 1 having a heart attack.

Findings included:

Patient #1's medical record reflected she was admitted to the hospital's main ED on 02/01/12 at 8:27 PM. An order was written on 02/01/12 at 8:40 PM for a blood sample to be drawn for tests including cardiac enzymes. The diagnosis documentation dated 02/02/12 at 12:21 AM reflected an "elevation of cardiac enzymes - could be a lab error." The discharge summary dated 02/03/12 at 12:32 PM reflected patient #1's "initial cardiac enzymes drawn in the ER were elevated but this was later thought to be a lab error."

Patient #2's medical record reflected he was admitted to the Hospital's ED on 01/18/12 at 12:37 PM with a diagnoses of Coumadin toxicity and chest pain.

During an interview on 03/20/12 at 12:40 PM Hospital Personnel #3 stated that the process of printing out a patient label and computerized lab requisition "did not happen in this case [Patient #1] and the lab person printed out a requisition with the wrong patient name."

Hospital Personnel #8 stated during an interview on 03/20/12 at 1:20 PM that if a patient specimen came to the lab without a requisition sticker, lab personnel would go into the system and pick the patient and physician order. For Patient #1 "they picked the wrong patient."

Hospital Personnel #10 stated during an interview on 03/21/12 at 9:15 AM the lab processed an ICU patient's blood with ED Patient #1's identifying information. Hospital Personnel #10 stated lab technicians "sometimes" called the ED and told staff they "had blood and no orders."

The Hospital Policy Nursing 03-003 dated 09/10 reflected the expectation to "obtain the lab generated bar code label and verify test and times with the physician orders...collect the ordered specimen...and attach barcode label...to the specimen tubes."