On June 19, Kent Hospital (Kent) notified Rhode Island Department of Health (HEALTH) of a wrong-site procedure in the interventional radiology department. A patient had a long-term IV catheter (PICC) inserted into the incorrect arm. During HEALTH’s on-site inspection, Kent reported a second case where a patient had dye for an x-ray injected into the wrong hip.
HEALTH discovered several problems in the hospital’s interventional radiology department including failure to follow established hospital time out procedures for six out of eight cases reviewed, radiology equipment that had not been inspected or had out-of-date inspections and unqualified staff using radiology equipment. A detailed description of the findings from the inspection can be found in the deficiency report (see http://www.health.ri.gov/discipline/hospitals/KentFindings200907.pdf). Inspection of the OR and cardiac catheterization lab at Kent found no problems.
In response to the deficiencies, Kent signed a consent agreement that outlines steps they must take to correct their deficiencies. In addition Kent’s Interventional Radiology Department has been put on probation for at least six months due to the pervasive problems identified. Each of Kent’s interventional radiologists is being referred to the Board of Medical Licensure and Discipline to determine if any disciplinary action should be taken.
“With the recent state-wide focus of preventing medical errors in hospital operating rooms, this is particularly concerning,” said Director of Health David R. Gifford, MD, MPH. “While we determined this issue is isolated to the interventional radiology department, the fact that the efforts in the operating room were not being adopted in the interventional radiology department is unacceptable.”
The hospital signed a consent agreement that includes: · Hire a consultant to evaluate interventional radiology policies and protocols for compliance with national best practices and then reports to HEALTH on their recommendations. · Observe and monitor the interventional radiology department and submit monthly reports to HEALTH for six months. · Contract with a patient safety organization (PSO).
-more- · Provide continuing education for the radiology staff and develop an education plan for any newly hired radiology staff in the future.
· Provide proof of up-to-date inspections for all radiology equipment within two weeks.
Additional conditions are described in the full consent order (see http://www.health.ri.gov/discipline/hospitals/KentConsentOrder200907.pdf)