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BRATTLEBORO MEMORIAL HOSPITAL 17 BELMONT AVE BRATTLEBORO, VT 05301 June 24, 2015
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on staff interviews and record review the facility failed to utilize their established event reporting system to collect information related to an adverse patient outcome and analyze the cause in an effort to identify opportunities for improvement and implement preventative actions. (Patient #1). Findings include:

Per record review Patient #1, whose medical problems included a condition that placed the patient at high risk during pregnancy, was evaluated in the Birthing Center for onset of labor on the evening of 3/23/15. The patient was initially examined by a CNM (Certified Nurse Midwife), and subsequently remained on observation status for a period of approximately 3 and a half hours during which contractions became less frequent and of shorter duration. An exam by an RN (Registered Nurse) determined no cervical change, the CNM was notified and ordered a discharge with specific instructions for the patient to contact the provider if she experienced any further contractions or other signs or symptoms of labor. The patient returned to the ED (Emergency Department) approximately 12 hours later, on the morning of 3/24/15, following an unanticipated home delivery with serious complications and harm resulting.
Despite the negative outcome for the patient, staff failed to complete an event report and conduct an RCA (Root Cause Analysis) to investigate the incident in accordance with the hospital's Incident Reporting policy. The policy, which had last been reviewed on 8/15/14, stated: '....IV. Procedure:....B. incident reporting is to identify processes and systems that need improvement...C. The data collected is used to identify opportunities for performance improvement. If the incident is at a level where serious harm may have occurred a RCA should be performed to ensure all steps and issues of the process are examined...V. RESPONSIBILITIES....C...1. Sentinel events [defined in the policy as an unanticipated outcome resulting in death or serious physical or psychological injury] have a root cause analysis (RCA) performed and are referred to the Peer Review Committee....D....The employee or member of the medical staff most closely involved with the incident or having special information is responsible for initiating the report.'
During interview on the afternoon of 6/24/15 the Risk Manager and the Director of Quality both confirmed that although an event report should have been completed it had not been done. In addition, they also confirmed that, although it had been 3 months since the event occurrence, no internal investigation had yet occurred to review care and services in an effort to identify any possible opportunities for improvement, as they were waiting for the completion of a peer review before conducting an RCA.
The CMO (Chief Medical Officer) stated, during interview on the morning of 6/24/15, that s/he had experienced difficulty in locating a source, outside the hospital, to conduct a peer review of the case and confirmed that although a source had recently been identified a peer review had not, to date, been conducted.