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NORTH SHORE MEDICAL CENTER - 81 HIGHLAND AVENUE SALEM, MA 01970 Dec. 11, 2019
VIOLATION: SAFETY POLICY AND PROCEDURES Tag No: A0535
The Hospital failed to demonstrate an adequate training program for Radiologic Technicians related to Universal Protocol.

According to the procedure titled "Universal Protocol", dated January 2014, the purpose of the policy to prevent wrong site, wrong procedure and wrong patient surgeries/procedures applies to the Interventional Radiology Suite.

During an interview on 12/10/19 at 9:15 A.M., the Interventional Radiology (IR) Operations Manager said her IR technician staff undergo a three month training program. Recently hired staff now receive the full competencies that Operating Room Technicians receive. The Interventional Radiology (IR) Operations Manager said that the Department adheres to the World Heath Organization (WHO) Interventional Radiology Safety Checklist but she was not certain that formal training for Universal Protocol was done with her technicians.

The Lead Interventional Radiology Technician showed the Surveyor where one of the (WHO) Interventional Radiology Safety Checklists were hung. During an interview on 12/10/19 at 10:00 A.M., the Lead Interventional Radiology Technician said that training for the Interventional Radiology Department also occurred during meetings and updates but was not certain of the Universal Protocol training.

During an interview on 12/11/19 at 8:00 A.M., Radiologic Technician #1 said she received annual training on Universal Protocol during inservices and a Health Stream on-line program. The Surveyor reviewed Radiologic Technician #1 training records and was unable to locate any Universal Protocol training during her years as a radiologic technician.

During an interview on 12/11/19 at 10:00 A.M., the Director of Surgical Services said she was the Operating Room Nurse Educator until one month prior to Survey. The Director of Surgical Services provided the Surveyor with the competency tool that was used by the Operating Room Technicians annually. The tool indicated the six elements that the technician must demonstrate to meet his/her competency. Also, a course bundle containing Universal Protocol policy review was presented each year.

The Interventional Radiology staff were not receiving the same education and training that their counterparts in the Operating Room setting had received.