Prevention Strategies Archive

October 2009:

Event: The lack of a process for counting devices pre and post knee replacement and the assumption that the surgeon reviewed post-operative x-rays resulted in the retention of a fixation pin for 3 days after surgery.  Two surgeons simultaneously performed bilateral knee replacements.  Surgeon A finished first and left the facility.  He assumed his partner would check the post-operative films.  The radiologist saw the foreign body and did not call either surgeon, assuming they would check the films.

Facility Strategy: Hospital policy now mandates pre and post procedure fixation pin counts.  The surgical group has mandated review of post-operative x-rays on the day of surgery.  Radiology will contact the surgeon directly when an unusual finding is noted on a post-operative x-ray.

September 2009:

Event: Several suicide attempts have occurred on units that have locks on bathroom or patient room doors. One patient locked himself in the room while attempting to harm himself. The staff had to scurry to find a key to open the door and rescue the patient. Even with an aide on 1:1 duty standing at the door, another patient was able to slam the door closed and lock it before the aide could respond.

Facility Strategy: Although many facilities consider locks on bathroom doors a privacy issue for patients, it is also a safety issue. The safety issue not only affects suicidal patients. Patients may have a syncopal or ischemic episode while behind a locked door delaying staff access to them. Therefore some facilities have systematically removed all locks from bathroom doors. All facilities should reconsider the use of locks on patient rooms and bathroom doors. At the least, there should be a prepared plan for emergency access to locked rooms.

August 2009:

Event: A lack of communication led to a delay in surgery for a trauma victim which contributed to his death. The on-call Trauma Surgeon was in surgery when the patient arrived in the ED and failed to notify the second on-call Trauma Surgeon in a timely manner. Once called, there was an additional delay because the second on-call Trauma Surgeon had a distance to travel. 

Facility Strategy: The Trauma Second On-Call policy was amended and now states that if the Trauma Surgeon is going into surgery, he/she must notify the second on-call Trauma Surgeon. Upon notification, the second on-call Trauma Surgeon must promptly present to the hospital to provide coverage. Elective surgeries are not scheduled for the on-call Trauma Surgeon, unless a second Trauma Surgeon is immediately available to provide coverage.

July 2009:

Event: The lack of understanding by new staff regarding the difference between Advanced Directives and the “Do Not Resuscitate” (DNR) order resulted in the death of a patient who wished to be resuscitated. In other cases, patients who had a DNR order have been resuscitated with resulting morbidity due to lack of communication.

June 2009:

Event: A newborn boy of immigrant parents had a circumcision performed. The father later stated that he did not want his son circumcised. The nurse discussed the circumcision with the mother and father in the delivery room immediately after the child was born while helping the mother breast feed the baby. The mother did not speak English; the nurse did not feel there was a language barrier with the father. The mother signed the permission form and a covering obstetrician performed the circumcision.

Facility Strategy: The facility now requires documentation of the discussion regarding circumcision during the prenatal period. If the parents do not want the procedure, the Attending will document NO CIRC in the medical record. In addition, the need for and availability of proper translation facilities for communication with patients who have limited English proficiency will be stressed with all staff.

May 2009:

Event: Two patients were unexpectedly hospitalized following procedures at ambulatory surgery centers. One patient developed wheezing and stridor; the patient failed to mention a recent diagnosis of asthma and prescribed inhaler. The second patient vomited and aspirated immediately post-op; he had failed to follow the (NPO) no eating/drinking/medication instructions prior to the procedure.

Facility Strategy: Both root causes were related to availability of information; a failure to identify important information related to the patients’ procedures. After a review of their pre-admission assessment processes both facilities developed improvement strategies such as: 1) additional trigger questions to help the patient recall physician visits and any newly prescribed medications; 2) more focused patient education on NPO instructions prior to surgery including the potential consequences of not following this rule.

April 2009:

Event: A delay in care for a patient with a Stage II Pressure Ulcer led to its progression to Stage IV, because the system’s communication failed to obtain a wound care nurse, dietary consults, and the specialty equipment needed for off-loading pressure in susceptible skin areas.

Facility Strategy: The root cause of the delay was related to the lack of appropriate laboratory data and pressure ulcer risk scores in their EMR which would automatically trigger the dietary and wound care nurse consults. The solution was to work with the RNs and the IT unit to coordinate the information so it was clearly presented on the computer screen and programmed to produce the automatic request for these consults. Additionally, the physicians agreed that RNs collaborating with the wound care nurse could order the specialty beds based on agreed upon criteria.

March 2009:

Event: The lack of a sponge count and the lack of an examination following a spontaneous vaginal delivery led to retention of a sponge in two cases. This resulted in discomfort, fever, and a foul smelling vaginal discharge, which required a repeat admission and treatment with antibiotics.

Hospital Strategy: Some NJ hospitals have implemented a sponge count before and after a spontaneous vaginal delivery presenting the argument that a manual examination prior to discharge is painful to the patient. Other NJ hospitals have indicated that the sponges used during a vaginal delivery absorb more than just blood, i.e., feces, amniotic fluid, and therefore performing a sponge count is not practical. They have instituted a manual vaginal examination in the Delivery Room. Either approach is appropriate and will help decrease the number of retained sponges after a vaginal delivery.

January 2009:

Event:  Lack of continuity of medical care for patients in Behavioral Health Units has contributed to delayed medical treatment, resulting in increased morbidity and mortality. 

Hospital Strategy:   Hospitals have implemented daily mandatory interdisciplinary rounding on each patient with medical problems who is admitted to the Behavioral Health Unit. As an alternative strategy in some hospitals, patients are followed by one medical doctor throughout the hospitalization. Monitoring is performed by the VP of Medicine and Nurse Managers.

December 2008:

Event: The patient fell while being transferred from the commode to the bed. The patient had a previous amputation above the knee and he refused to wear his prosthesis. The patient care technician assisted him to the commode. He pivoted toward the side of his intact leg to get to the commode but pivoted toward the side of his amputation to get back to bed. He fell during the transfer back to bed.

Hospital Strategy: The RCA Team discovered that training for patient care technicians included transfers but did not specifically address certain patient populations, such as amputees. The training now addresses special populations and includes role playing and demonstration of transfers. The hospital has also started an SBAR report for patient care technicians to include specific information, such as the amputee status.