HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that performance improvement activities analyzed the causes of one of two adverse patient events. (Patient 12) This failure had the potential for undetected causes to persist and result in additional adverse events.

Findings:

On 3/18/15, the performance improvement activities were reviewed. The hospital adverse event worksheet for Patient 12 indicated that Patient 12 required cardiopulmonary resuscitation (CPR) during a colonoscopy (a procedure to view the inner lining of the gut). The worksheet contained a section for a root cause analysis of the event which was blank.

On 3/18/15, the hospital policy, titled, "Sentinel (could result in death) or Near Miss Events," dated 5/16/06, read, "The incident will be described in detail, including the time sequence and staff involved, etc. Root causes of the incident will be identified. The actions taken immediately after the incident to limit the adverse consequences to the patient will be described. A statement as to whether or not those actions are judged to be appropriate, adequate, and timely provided. If members of the committee are unable to judge the interventions, consultation will be sought and the consultant's conclusions will be entered into the report. The causes, conclusion about the incident , and whether or not it could have been prevented will be stated. Recommendations for action to prevent such an occurrence in the future, including changes that affect all involved departments will be stated."

On 3/18/15 at 11 am, Administrative (Admin) Nurse A stated that Patient 12 was transferred to another hospital and died. Admin Nurse A reviewed the worksheet and acknowledged that a root cause analysis was not done according to the hospital policy.