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Based on interviews and documentation review the Hospital failed to identify all opportunities for improvement during an investigation regarding a wrong site surgical procedure.

Findings included:

The medical record review indicated that on 4/2/10 the alert and oriented Patient was transported to the Hospital's Emergency Department (ED) after falling and sustaining injuries. The Patient presented with an abrasion on the right elbow without deformity and without limited movement however; there was pain with movement. The Patient had an obvious deformity of the left wrist. Radiologic studies were performed. The studies identified the Patient had a nondisplaced fracture of the right radial head (right elbow) and a displaced fracture of the left distal radius (left wrist) with foreign body projection (sling). The Patient was referred to an Orthopedic Surgeon and went to the office for consultation on 4/5/10.

The Orthopedic Surgeon was interviewed on 4/21/10 at 8:45 A.M. and the History and Physical (H&P), dated 4/5/10, was reviewed. The Surgeon reported being aware the elbow x-ray was of the right elbow. The Surgeon said and documentation indicated that the Surgeon reviewed the Patient's x-rays (also confirmed by reviewing the activity report regarding the x-rays). The Surgeon said and documentation indicated that when the Patient was examined, the Patient's left elbow was painful and there was limited function. The Surgeon said and documentation indicated that the Patient had no limitations or pain in the the right elbow. The Surgeon said the Patient agreed to surgical repair of the left wrist and left elbow which was scheduled.

Review of the Consent Form, dated 4/5/10, indicated that the Patient consented to an open reduction and internal fixation (ORIF; surgical incision and placement of screws to fixate and stabilize the fracture) of the left wrist and elbow.

Review of the Operating Room Schedule, dated 4/7/10, indicated the Patient was scheduled for an ORIF of the left wrist and the left elbow.

The Orthopedic Surgeon said the Patient reported in the pre-operative area just prior to surgery of a previous elbow fracture but could not remember which elbow had been fractured.

The Circulating Nurse was interviewed on 4/21/10 at 12:50 P.M. The Circulating Nurse said during the surgical procedure the Orthopedic Surgeon requested that the pre-operative x-ray of the elbow be pulled up. The Circulating Nurse said there was only an x-ray of the right and not the left elbow. The Circulating said the Surgeon reported that he/she may have been looking at office films. The Circulating Nurse reported being concerned that the x-ray was mislabeled and reported the finding to the OR Charge Nurse. The Circulating Nurse reported calling the Surgeon's office to inquire about the office films and told there were none.

The Director of Surgical Services was interviewed on 4/21/10 at 9:00 A.M. The Director reported being notified of the potential Radiology error while the Patent was still in the OR, investigating, and determining the x-ray had not been mislabeled.

The Circulating Nurse reported looking at the Patient's right arm after the Surgeon finished the surgical procedures and noting the underside of the arm was bruised.

Review of the Operative Report, dated 4/7/10, indicated that the preoperative diagnosis was radial head fracture left and distal radius fracture left. The postoperative diagnosis was radial head chondral (cartilage) fracture left and distal radius fracture left. The Report indicated that there was no pre-operative x-ray of the left elbow due to mechanical block (sling). The Report indicated that when an incision was made the left elbow was examined. There was fluid consistent with an old hematoma which was evacuated. There was no significant displaced fracture, only chondral fragments that were removed. Elbow range of motion was improved and therefore fixation was not done.

The Circulating Nurse reported asking for the fragments at the end of the case to be sent to Pathology and was told there were no fragments only mush.

The Director of Surgical Services was interviewed, the Vice President (VP) of Quality and Risk Management and the Quality Management Coordinator were interviewed together on 4/21/10 at 2:20 P.M. and the Hospital's investigation was reviewed. The Director, the VP and the Coordinator said an immediate investigation was conducted that included interviews of staff involved and medical record review. Findings included: 1). the ED final diagnosis did not include the elbow fracture and did not identify the side of the wrist fracture; 2). the procedure was a wrong site surgery because the x-ray identified the elbow fracture as the right side, there was no x-ray of the left elbow, the Patient was assessed for a left elbow fracture, and surgery confirmed there was no left elbow fracture, and 3). the Surgeon did not document the error in the medical record. The investigation confirmed that the Time-Out processes was appropriate.

The Hospital investigation did not identify that all staff present during the surgery did not participate in or were not documented as participating in the final Time-Out.

Review of the Interoperative Record, dated 4/7/10, indicated that a Physician Assistant (PA) was listed as an assistant and a Radiology Technician (RT) was present to perform x-rays.

Review of the Patient's Time-Out Record, dated 4/7/10, indicated that the PA and the RT were not listed as participants in the Time-Out.

The PA and the RT were interviewed on 4/21/10 at 1:15 P.M. and 2:00 P.M. respectively. The PA reported not remembering the surgery however; did participate in Time-Outs when assisting with surgical procedures. The RT reported waiting outside the OR while the Patient was being prepped and entering after the surgery had started.

Based on interviews and documentation review the Hospital failed to implement corrective actions in a timely manner and failed to develop action plans to address identified deficient practices.


Findings included:

Please see A-0287

The Vice President (VP) of Quality and Risk Management and the Quality Management Coordinator were interviewed together on 4/21/10 at 2:20 P.M. and the Hospital's investigation/ recommendations was reviewed. The VP said and the investigation indicated that recommendations were made as follows: 1). address the documentation practices of the ED physician; 2). disclose to the Patient and to discuss treatment options with the Patient; 3). consider review of x-ray images immediately prior to incision, and 4). review office practices for possible improvement.

There were no recommendations to address the Orthopedic Surgeon's failure to document the surgical error.

The VP of Quality said the Surgeon had not yet confirmed that disclosure had taken place.

The Orthopedic Surgeon was interviewed on 4/21/10 at 8:45 A.M. and reported speaking with the Patient and was continuing to treat the Patient. The Orthopedic Surgeon reported speaking with the Patient in the presence of a nurse (SSU Nurse).

The SSU Nurse was interviewed on 4/21/10 at 10:20 A.M. The SSU Nurse said the Orthopedic Surgeon told the Patient that pins did not have to be put in the elbow and that a fragment was removed. The SSU Nurse said the Surgeon did not discuss wrong site surgery.

The VP of Quality and the Quality Coordinator said that no other actions had been taken as of the survey and that the case was being sent out for an independent external review.