Based on interview and record review, the facility failed to report 1 of 2 preventable adverse events (PAE) to the Texas Health Care Safety Network (TxHSN) and to complete a root cause analysis (RCA) for 1 of 3 adverse events reviewed.
Findings include:
Interview with Chief Nursing Officer ( ID# 51) on 11/1/2016 at 2:20 PM revealed that adverse event (wrong surgical procedure) performed 3/11/15, involving patient (ID# 3) was not reported to the state as required and that it should have been.
Interview with Chief Nursing Officer (ID# 51) on 11/2/2016 at 9:35 AM revealed that in regard to adverse advent (wrong surgical procedure) that occurred with patient (ID# 3) on 3/11/2015, there was no incident report generated when the facility was notified. There was no documentation of a root cause analysis (RCA) performed regarding the event. There was an investigation performed, but no documentation to review that shows the investigation process.
Record review of Texas Department of State Health Services Facility-Specific Healthcare Safety Report of preventable adverse events reported from January 2015-July 2015 for Conroe Regional Medical Center reveled the following information.
Preventable Adverse Events (PAEs)
Events related to patient care: Total Number of 1
Patient death or severe harm associated with a fall in the healthcare facility that caused a broken bone.
Record review of the Texas Department of State Health Services 3 Tier Phase -In Implementation for Preventable Adverse Events (PAE) revealed the following information:
First Tier PAE Reporting Beginning January 1, 2015
1. Surgeries or invasive procedures involving a surgery on the wrong patient, wrong procedure.
10. Patient death or severe harm associated with a fall in a healthcare facility resulting in fracture, dislocation, intracranial injury, crushing injury, burn or other injury.
Record review of facility policy titled Event Reporting: Patient and Non-Patient dated 01/2012 revealed the following information:
Purpose:
-To provide a record of events and documentation of the facts
-To provide a base for further investigation with a focus on a patient safety and environmental safety processes and systems, and the corrective measures needed to prevent recurrence and sustain improvement
-To collect data for statistical analysis
-To fulfill regulatory requirements for reporting events
-to alert Risk Management to potential claim situations
Policy:
-Adverse events, errors, unexpected events, variances, incidents, and near misses involving patients will promptly reported online in the Meditech Risk Management Patient Notification System even if the event seems insignificant at the time.
-Event reports are intended to provide a record of the event and document the facts
- Event reporting is an important part of the Hospital-wide focus on safety and performance improvement.
- Event reporting is a system of notification to Hospital leadership of actual or potential risks and patient safety issues/concerns.
-Events reports should be completed during the shift the event occurs or is discovered to have occurred.
Supervisor, Manager and Director Review responsibilities:
2. Service leaders are responsible for prompt (within 72 hours) initial review of all information entered by the employee and for conducting an investigation to determine root cause and follow-up to ensure resolution of identified issues/concerns.
4. Results of investigations should be shared with the staff with a focus on process and systems design and redesign and outcome, and the corrective measures needed to prevent recurrence and sustain improvement.
