The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|MASSACHUSETTS EYE AND EAR INFIRMARY -||243 CHARLES STREET BOSTON, MA 02114||Aug. 30, 2018|
|VIOLATION: PATIENT SAFETY||Tag No: A0286|
|Based on document review and interviews, the facility failed to provide sufficient evidence that the hospital's quality program implemented a thorough corrective action plan that would identify and reduce future potential medical errors.
The document titled, Improvement Action Plan (a plan in response to Patient #1's missed Lidocaine allergy on 06/21/18 that resulted in Patient #1's anaphylactic reaction and decline in condition), stated that re-education of anesthesiology staff was completed by 07/26/18.
The document titled Anesthesia Lectures for Eye and Ear Infirmary (a presentation that discussed Patient #1's missed Lidocaine allergy on 06/21/18 that resulted in Patient #1's anaphylactic reaction and decline in condition), dated 07/26/18, displayed 21 of 44 missing attestations. The Facility could not provide documentation that all other anesthesia team members were made aware of the 06/21/18 Lidocaine allergy event and were educated on corrective actions.
The Surveyor interviewed Physician #1 at 9:55 A.M. on 08/29/18. Physician #1 said she was unaware if the department had conducted any changes or corrective action after the 06/21/18 Lidocaine allergy event.
|VIOLATION: ANESTHESIA RECORD||Tag No: A1003|
|Based on record review and interviews the Hospital failed to provide, for one (Patient #1) of ten sampled patients, a thorough and complete pre-anesthesia evaluation. Patient #1's drug allergy of Lidocaine was not appreciated and led to Patient #1 suffering an allergic reaction, a decline in condition and an emergent transfer to a tertiary care facility.
The medical record section titled Allergy Review History for Patient #1, dated 06/12/18, indicated that Patient #1 had an allergy to anesthetics - Amide Type (Lidocaine is an amide type) with a comment of bradycardia (low heart rate).
The document titled Anesthesia Postprocedure Evaluation, dated 06/21/18, indicated that Patient #1 experienced anesthesia complications and required multiple pressors (medications to help increase blood pressure). The surgery was aborted and Patient #1 was taken to a tertiary care facility's emergency department.
The Surveyor interviewed Physician #1 at 9:55 A.M. on 08/29/18. Physician #1 acknowledged that she (Physician #1) did not fully review and assess Patient #1's drug allergy history. Physician #1 acknowledged that the lidocaine allergy did not come up on verbal handoff with Physician #2 (the physician who was in the operating room and administered the lidocaine to Patient #1).