.' .LIt! ,1, 111,\ 1-,1: ,,( I , j AND l ;lJMAN !id~vll-ES A~;t:NL"Y

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(~ . 050010 1I -'lING 03/30120 11

rr,<,>.if. OF .,1tQV!i)(R OR ~UI' PIJER :;TflEEl "~ess. CITY ~ l "Tf ~oP COOf.

KA ISER FOUNOATION HOSPITAL · SOUTH SAN 1200 EL CAMINO REAL, SOUTH SAN FRANCISCO. CA 94080 SAtJ MATEO COUNTY

FRANCISCO

'~ .l i() , IJMWoIt'f $ 1,1, Tf lo«:Nl O~ OEf 'CIHICI\:S "

· !' o:.'III.'E-~ S P ....... Uf C(JIIRi"<; l IC .. "PH I~ 1 /i.eli CHI<:I[HC~ MUST SE PHE C"IOOEO BY HAt " IIHI) ( .Cf.< r.."R~EC livE ,o.c flOIi '>I-0..Il..0 '* C~O 55·

: ,,(, ' f~>U\.A TCRY 0f'I 1!;C IDENTW VING INFOIlWoYION) I ~ G ;;;U' E~ENCEO TO wr "~PRi)PRII'IE GErIe '[NC f! , 1

rhe following reflects the findings of the , , , Oepartment 01 Public Health durit19 an

, CA DEPT OF PUBLIC HEALTH ,

: mspEtctlon visit: ,

Complaint tntake Number: ,

, CA00258737 · Substantiated , AUG 1 3 2012

, , Representing the Department of Public Heahh: UlCDIW;!ClN Surveyor 10 II 21155, HFEN

SAN FRANCISCO , ,

The lr'lspectiOl'l W8,llmited to lhe speQllc facitity

event Investigated and does not represent the f indings of a tuli inspection ol lha facility .

Health "d Safety C""_ Section t280, He). F OI i Health and Safety Code 1280. 1 ( c) purposes 01 IhlS sechon "immediate jeopardy " , Immsdlale A~tion B~A: means • situatIon '" whIch <h_ hcen~ett"s • Root ('aust Ana lysis ( RC AI noncompllam:;e NJlh on. 0' more reqUIrements , was performed to assess , 01 licensure has caused, 0' " likely '0 cause, , co ntribut ing faC IOrs and to 'erlOus InlurV or death to the patlenl. develop a corrective plan of

ilc tion to prevent fu r1 her

Abblevlations and Glol5sry , incidents. , , The RCA was , ,

condUcted by the ; 1 )Abscess • An enclosed collection of, liquefied I , !

tissue, known as pus, somewh9r, in the body . 1 Direclor of Risk It is the result of the Dody's defensive reaction i Management lind

to foreign malenat , the AssiSl ant

I Physician in C h ie f

ror R isk

2)Chordoma . Rare tumOt thai usually occurs Managemenl ,

,n 'he spIne .nd base of rho skull II " • ; Partic ipants malignant tumor included the

Registered ~ CJ". Surgeon ,

3,Circulator 0' CIrculating Nurse Ci rculating NUrSe,

NU/se who ;, responSible fo' deltveflng quality '1'ac "'\5t?" ..... ~ G/'"/" and Pcriop(' l1Iti ve

nurSing care to the patlOnt In the OR OI-~ " Scr.icc=s Direc!Or. £

lO ... ent IO'XOON1 1 ',i/1 4120tt 2: 2!i !8PM

PPI.'ER REPRESENfl>TI 'IE'S SICNA tURE linE

'"57< . • , " le~' ~ ,1eI1<" "enC), ,,"0(" ,n. ".1.1"""" m.¥ ,,,. u, ... ~.., !.,,,, ~C""~'''''l D'O ', 'J '~'~'e ' ''' ' ''''(1

~ ~t ,),n.' . aTe'l U;O ,<,I 1 pr.,,,ae ,u~, : ,e~t p'O!K !lQn to me MI""". E,~eCt !Of ""'''''''l'lomn ~e !fid"'". ~~~ , • •• e n o..,. 'c'e 0': , .. , ' ~ . ,~" 'u "' e t " .

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':,'llronNIA I lEAL TI l ,\f'IO HU ,,",IAN :$ERVICES {ll>El'iC 'I'

;)f.P"'H rrllENT r)F PUBUC HEAL TH

~~~~~~------------.~------------.-------~ ',1",1 ",UI r o. ,II I oC"".tlCIl S '._(" , Fl C'I1t'l1 FlISI$'I't'I·RiC l ,,, r.<~i 'M flh l Cor, S71l1!C 11""" ,, ' 10 PI ~N u l '~ (1 F1~ ~f. 1Ir;~ ' l'ltITLHt;.I. I ViN MJMIlI: II

• ', 0" 11 !>\.>!'~ l '

-' ,.<I·U 'f')

050070 II WI~G 03130/2011

<;l'I!;n "OO RE SS. Clry ~lAIE .!JP COOE

KAISER FOUNDATION HOSPITAL · SOUTH SAN

FRANCISCO

1200 EL C'&'MINO REAL, SOUTH SAN FRANCISCO, CA 94080 SAN MATEO COUNT'I'

' .0.4.(,1

I P'IlX

"'.r;

; , i

:UYlMfiV .. 1._ Tn~ Nl OF CI'FICI£_NCIES 'I, ,\CH I:H ICI(;"oCY ~():; T I1 E :" RE CHOt O OY ~ liLl

" I":'UI..&TOFlY OfllSC (.l( NTlf .. " ,,:; tJoof QP ..... ' KII'II

, Continued From page 1 , : (operating room) using Ihe nursmg process ' \ This RN makes preparatIons lor an operation I

,~nd continually mOnitors the patlenl and staff ' I dunng its course, who works In the OR oulside I

' Ihe Iter ~e field in whICh the operation takes t pIece, and who records the progrel' 01 the I operaUon, accounts lor sponges , irlslrumenls , I

, and specimens. I

i ~ )Cu l"'llii near Densrty A mass of ,

mailer

I ilppeanng as a CUl"\le, nonlinear

, !)Jan ,cenumetsr

i 6 )Courlter Bags , (sponge hol,jer 'Jags) . . , r ri\osparent bags I individually Inserted alter they are counted.

11'1\0 "hlch $p(>nges are I by the CIrculating nUfse.

, 7)CT Scan . Computed romogfaphy , computerized Il,ray procedure, A produces cross· sectional Images 01 The tmage. are lar more detailed

So'" c r ". m",

A! scan '

boo, l · fav

I1Ims, and cen relleal disease or abnormahtles !

I in "Slue and bone.

: 8)D1abetes A group 01 metabolic diseases In , 1 which a person hu high blood glucose either !

becauM the body does not produce enough 'I insulin, Of because cells do not respond to the

l ,nSulirl thaI IS produced.

: 9)Erec101 SpInae Muscle The superfIcIal I

longItudinal muscle mus on eIther side 01 the I

'Isrtebral column II ansas In a broad , thIck

b unt 10 xQON1 1 ?i 1411011

,

~ r> OVIC(R s I"'t.AN Of ~CRN"C nON

.! AC t'< CQRRfC ri'1F. &CTIOf4 Sf<oCUlC SE {.I'OSS,

"rH Flf NCEO (0 ' I"f """PO~"' TE CfF,,: " 'K",

5 ~

n-, -(!) ~ «

0 ~U (" ' 0 : '~ G ... ~ ~ 0"-

:l~

The RCA focused Iln potential human factors which may have resulted in Imot. possible environmental factors (such as noise. equipmcMI, elc) and polclltial process fa ilures which may ha ve resulted in the error. Olher potential factors explored included stalling level, orientation and training of staff, competency Ilssessment and crcdent ialing. supervision of

staff. and communication among stan' members. A literature revie w was conducted .

.J r he lindings of the root cause analysis were: I) the linal ~pon&e count from Ihe surgical procedure was correct. and

' 1'1 f

" I J,,"C'," "C~ eme nl u"'g .. Un ~" ~"e"s~ " .... . "'Ie' .. <reloc .. nt y ~ n'tn 'n. r: Wlut'C" ..... ily t . e · t"~." "om tCf'e(.I" .... PIC'''''''Q , >s ! .. Ie''''...eo

"-11 ,l,,,," laI1!9" " ,<l1 ~"" '-.H \\.>11.: .. ", F'1)le.:'lOn 'o~"., ~ " , .• nl\ i 'cepl too """<Oq '->Or"!.ts I~. '100""01 aDO,'a .,. ~,.c~uCl. :I{) llalS l"ik;hYln9 : ~. Ill'. , ,,", "1 "''',"M' ... ~()1', elln JI '~O't ~CI.cn ,I ()'o,,~etl Fc:, ~"" 'n9 ~om')$ ,I'. "00". 1."<1"",1 '. ,,,, plMOi QI ~O"K"<>n JIt :l11CIOUOIe q .l.oy" '0110 ... ... 0

.. n ,1 ,1\, ,~ ... " ' l'Xt.''' ..... b .. ~ -n~ue • · •• ~ .. o'l! :e " .... 11C '<1" ! -'.fo:~"c.e' ~ , e ~, ,,,c J Il , ~ ~' O ,.O P'''" ,01 :o,",ellOfl S r~ ' l ''' ''l. 10 :CH lhrLe n p."~' .. m

0""" ,",. 'J;'

<~ I

.e M""-', rl ~ . I ~

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:iUI CRNIA Ilb\ll 11 \ NU l ·lJ~!I.\,N SEINtt;E S NjENCV ; f.F A[i HAEN r ()F PI ibllC i tEJl.l n t -3IMr V(N I Of' CP !CIENe,,,S ' ~ I i "~O"'IO~I!IS~'I'PlIUI/ClI'" !'<7) IAlIl IIPt.t. CCrlS IMtJ(:loQN " ! I .,_QL ~,",J< H'f ~ ,j()I'L_N (;' r;:PM~cr.CN cr NrlF lI;,Ior;Ol-l NUI~BF.II - \If'11 ;r [l

10 ~U'LC I"G

( ') 0$0010 ~ "N IO 03/3012011

'1A..n:. Of l>"OVlClII OM SuPPUE R ~IRHr AOORE5S. Clf't . 51. reo LIP eOCE

KAISER FOUNDA TlOK HOSPITAL· SOUTH SAN 12oo!L CAMtNO REAL. SOUTH SAN FRANCISCO, CA 11.010 SAN MATEO COUNTy FRANCISCO

1.<41'0 , .uMJM.fI~ Sl~ I£MEeNI Of OE f lCllMCIfS ,

" IIO'M ER'S P\AN (If <;O~"lC nc •• .. ,'lirn l< ' 'CII OI' f l(;lf l#CY \lVS"T BE I'R('C[[D(O BY flJl.l

i i1HIX ,i~ ~H CCI>"ECTlvE ACllC tI 5HOULD!I.E ( 1I05S .<::W'UI(

I",) "II;UL~TCAY n R I SC IQ€Nf\fVIl-jO INFORIoU..TIOHI ,. ' H Hlf NCro It) 1'* """ROPP I.O. Iii. OE_f lC -= t#Cv' '"

Continued From page 2 i

, tendon Irom ,h. sacrum. ,h. Ileum. ,nd 'h. documented as . lumbar vertebrae. " inserts mto 'h. nbs .M such by lhe ! Into certain cervical vertebrae. , extends and ! 5 C irculating Nurse;

flexes In. vertebral column .M 'h. head. i and 2) the Medical draws ,h. nbs dQVfnward, ,nd bends "'e InJnk : US , Center policy for

, to the side. :r: ~

0 announcing and , 2:0 S,2 5 Q '.-!2 documenting

'" I --' ~ IO)Hairy Cell Leukemia - A rsre .. ""'" : :~ I..) tucked sponges had of whita bI_ cell called In.

<D M .- -I which • ~p, ~ ;;~ nol been followed

l lymphO(;yte. present in 'he b'ood ,nd bone j a.. - by the Surgeon. I marrow. be"""", malignant • nd proliferate • . "'

LL.-

'" " u. C irculating Nurse. D => :l~ , " called hairy cell leukemia because In. cells Ii:

, « and Surgical have My halT· like projections when viewed :

UJ r echnieian. under the microscope 0 ., The panicipanls in , «: the RCA discllssed 11 )Kick BuckelS . A melal receptacle '" 'h. OR : CJ

the possibililY thai used \0 throw waste a sponge fr om a ,

previous case may i 12j Laparotomy Sponge . Also "lap sponge" 0' have been lett in Hlap ,-" An ,nd absorbent ped constructed i

one of the kick of gauze , nd cotton with ,n embedded j

ouCkds in the OR, , radiopaque 'be, used '0 absorb fluids and I

, blood in SUrgery. , thus contributing to

, , I the erroneous , correct count.

t3)Mayo Starn:! . A sland where ,he sterile tray i ; lays in ,h. OR On ". tray are the II'Istruments i , Immsdjate Action p[ocgs that m,y be ImmedIately needed by the j C hanges: surgeon. , • As a practice change, the 2117 I ! ,

rl!sponsibility for r emov ing 14)MRI MagnetIC Resonance ImagIng lhe soiled liners front DiagnostIc techniqua whIch uses , magnetIc sponge kick buckets at th~ held ,nd radio waves

" prOVIde computerizeo ' conclusion or eac h surgical

Images 01 internal body tissues Case was transitioncd from , Environmental Ser v ices to

, 15)OR . Opera ting Room OR cl inical ~tall Linen: afl~ . henilO XOON 1 1

. 01 1412011 22;,18PM

,_S I OA;E , .ABQI.'",TI)RY IRECTOR-S OR PRQ'IIOEA/S UP Pl'EfI. flEPRESENl~n\IE '''' StGtM t UR E

/eb.y/I/ ' ''1 ' lel<C I~"':' ~ 1.,,,m" n l e ~a,nQ ',, 'Il"< I~ UI~"" I" danoles I il~IIC;,~n~y ' ... ,,>(;~ 11\. ~"~lutK!n ,.,.y be ~ .~uu" h om ~~'K\"'Q Plo~'IIc"9 " '\ ".'e fm",.,d

''' 31 ~ ln9' ,~t.<;Iul"U oro~.n ,uilICJe"' PlotKUon ID ll1e ~ ~~""\. F. . (8," to< "Ull .... ~ _ . I/le ,"'"...? .t>ov, ~I~ r. 'l~iO IJ b1 e 90 ~~'/I 'oiJO'"" "Q ina lale ,I . I " /~ ' ~n.tt>.' 01 "<II a ola" oj ~O"<!c I<ln" ~I ·'~'~eo . 01 '1"""' <1 nol1"'" '''' .UO •• r,~ o'rQ ' i n" '~"'" a ; 'I"'~~I- ~~ lie l " DO~'I)'@ IJ 1 ... .. 0'10..-' · ....

'.~ " '" '''' .... ' 1<x ~"." n l5 OJ" ,..~a, ~. ~~'O''':O ~ .. @ ''K''I~ I' ,,:r;~'.''''!e l ~,~ :,Iea ~, . C~ ·~· ... ~ "'I" ·1' ~ ~ .,~. , .,... '. t 'l , ",.' . ,- , ,' " ' .• il ,.' ' j ' '' , ' '

C)·· " '~~ I.'" •. ..

;AUt- OHNIA hfA!. !II I<NO ! I U ~lil\N S~HVIU ,S AI,jl::. llCY ,;I:PAH IMENI !)t: PUIlI It.: !'l'AlfH -'; ' M IMtI'" ,}t 1)1 ~I( IH,,-Ito& ,I' ,·J;\,;V.JfR,l'.:l,ol'VI II O{p.l .... . .• N!)Pt Jo" ,;j C')""I r.l.~N ":~ :'H:H: . I . ' 't, NI)MUH'

C 050010

CA DEPT OF PUBLIC HEALTH

";i \I,J!. I.·ll. ~CN~"I.UAOO 1 3 2012 t~' I,; ~ rl' ;t;"_ lt ~

· • ... gt I' ',l,;

". H.!Il('''1G Q 'tJ1NC, ute 0IV11ilCM 03/3012011

NIolott C",01 I'I-IOVIO("H OM SUI'P~ 'lR :,l I-lHl"OORUS Cll'< surf. 11l' CCOf o~~

KAiSeR FOUNDATION HOSPITAL· SOUTH SAN 1200 EL CAMINO REAL, SOUTH SAN FRANCISCO, CA 94080 SAN MATEO COUNTY

FRANCISCO

,i,, '1.1 L I,jWHY ,~T,t.T[OJENl or (l f~ ICllNCi€S , '" I . nOVIOlIn. "UN Q!- :';CR l-lfCr 'CN ... ,

, " I" ~ I ACI1 :':V !CIHI{;Y ""UST OE I'R~CHOtC IJY ~Ull , .. u,x I U.C~ COII:RECTI'/f. ~CTlON SIiOULO Ot CAO$ii. , MPll II I.'C. '· HAIU. IOIIY 011 ~ $C 'Cf.HTfllNf; lNfC""""l!QNI ~ ~o IlHEltfNCED ro',* ""'F'IIOPRIATf Of.f Ir.IEIf(.Y, t ~r[

I Continued From page 3 i

16JPafilsplnoos Muscles . Tho mUSCleS next t. I 10 be removed and d iscarded

tho spIne. rhey suppOr1 tho spine ",,' " 0 Ine ( by the Surgical Scrub

I motor for the movement of tne spine. ,

P~rson (RN or technician) , assigned 10 Ihe case. after

! 17lPelvis IPelvICi Th. lower portIon ., the ! ,

Ihe case is completed and .

i trunk, bounded anteriorly ,"d laterally by tho I the pallem has left the

' two hip bone' ood postenorly by tho sacrum : I Operating Room where Ihe

and ccecyx. procedure took place.

• As a practice change •

" 17/ 11 1B)Radlopaque . A" entity Ihat " Impenetrable I C ir<:ulllting Nurses were 10 x·rays Of other radIation asked to hang sponge holder

I bags (COUnler bags) back-

t9)Ray roo A brand name I •• , 4x4 Of ". I to-back. thus allowing each

gauze sponge WIll'. 00 embedded rlldlOjlaque . category of sponge fiber Also referred I~ as ",aylel(" $pong.s.

, (laparotomy sponges and

ray·tecs) to be placed in its 20)RFO . RetaIned Foreign Object

, own bag, wilh the front

I , sides of both bags being I

21)RN . Registered Nurse v isible simultaneously . This ,

•• i ensures that both bags can

, 22)RDO! Cause AnalysIS {RCA)· A class be visua lized by all team

problem SOlvIng methods aimed " Identifyu'lg t members (including the the rool cause of problems or events surgeon). withoutlhe necd ,

to " nip" bags back nnd 23)Sacrum . r ho large heallY bone " !ho base I (onh.

•• !he spine It " roughly triangular '" shape I

and makes up Ihe back wall of the pelvIS. Sntemic i\ct!Qn:

0 All Pcrioperativc clinica l ) ' 11 " Z4)5acrectomy EXCISIon •• 185.cllon •• the , slalT(Regislered Nurses . sacrum Surgical Technicians.

Surgical Assistants. and 4'5)5Inu$· A cavity , channel. or lecess Registered N urse First

, Assistants) receiwd re· 26)Subculslleous Tissue - rhe layer 01 loose education lUi Medica l

,. ',) 14!2011 , . .2516PM

"." :;. If,

<e/vtb 11.1 ... " nt ~ nJ."q " " ~.~ ntc,,,k ., I" IIOle • • j~,c,C~CY '~ "tcl\ Ine . ' \ "" J""~ ...,a. o. ,,_ct.,e., IIl)m :C" ,"CU'I) II .... . ''''''~ ' .. ~ ),,'.' .... ,"~d

h " x",,, ,al"911,,-oI Il'O;' oJe ' ultoel&n( :>I O' l'["on '0 ''1ft ~auert5 """ "", .... "',,, ... ,, rOlt'on a", ' ''''''' 11 aloe.e t'e ,,",,1n! .0I" j(I"';o~. '''';':'''/''1 11\ .. Jdle

I . ", .• 1 Ml"m. r <;Ir '"'' ~ . ' ~n ,," '.<:"''''1I0Il '' OfoJ ,o.:ed • ~ "',-",.n'l "'?n" ('S ... . at.:." . .... J,~~, .. rOQ ,~ ,...~ .Ji ,.,.,,~' ''''' ~,~ .""c:on<:>o" ,., d~. ·. ·,,,,,, ... nQ

( ) ::.:;,: :," "~"o .. ,, ".

, ,

. ,\l ;f ( HNI'\ t U:I.L i I I " NO HUMAN SERVICE S 1\' ,Et It;\·

"EPAR !I,IFN I ()F r:Uf] t Ie J lEAL HI CA DEPT OF PUBUC HEAlTH -r ,"""""'" "" .", ~"" " II 1·1I .. )·~ ICt; RI'>U4'f' lIl f/1": LlA ''': ;'1 IA\,1.1IPlE:CCNS r Flue 1 :(;. , " . 'J,(l.o>' f ~U"'''v ,,.~

,' 1m ' ,,, .. 01' -:·}ll l> t.C!l(lN r.\.Imn <: ,t. " e N III,M[lf ll ,

. ~ "\'f',1, lTD AUG 1 3 2012 ).>' ~

.: '~ . ~.:,,~ ,! " H,,',L ~,G " f ',,' . .. <-6 050070 .J ,'01G - 0313012011 . , .. MF CO' ;'/l OV'OUI Oil 't"*PlIIoR :, IMH f ~ OIl UFS S GIn Sl.T£. ~ OI' tOOf • ~~ VIVI;'I.,:!~ ~ '-KAISER FOUNDATION HOSPITAL · SOUTH SAN 1200 EL CAMINO REAL. SOUTH SAN~E~GWQ SAN MA TEO COUNTY FRANCISCO

, 4 1.0 MWAARY ~ rArU"OH Of CEf ICIENC:t'.ti " -;;'O' IIU[R'S PlMI OF C'JIO RFC1\O)'" " ,)

~"~Ic.. .\ A; H Of-nOH IC' MIJ$T tlE I-II FC£f.DlD UY H.:H , ern", ! ,I At; H CQtllil Cll'< f l .:: h Otl li t<O\JI 0 O! CI< O~S · . '~ MPlI.H

UG ." ClJ\.AIORY n il l SC 'DU. ,,,,y ItU' "'~Qfl M,t. nG'" " ·\G ' I I FII FNCED '0 ' >1, A~P FlC PIlI .. 'f. O,-" r, <fNf. " r,., f!

Continued From page 4

conneclive tissue directly under the skin

27)SurglCal Scrub TechnICian Refers 10 tM ' C enter Surgical Count ' urgical technician 0< RN who i, responsible for I Policy which includes the eJirecUy maintaining !h. stenle !leid where the I process for announcing lind operatIOn .. taking place, ",d 10f dellvenng !h. I documenti ng lucked

equipment i , sterile Instrumenla, supplies, ,,'d i Sponges. Staff participation

I directly to the surgical team. was mandatory. 1000/. of , staff completed required

training.

nUe 22 • Kaiser South San Francisco -t,51\ I 702131<1 ) Nu rsmg Servic e PoliCies and i Medical Center conducted a Procedures Surgical Safety Summit la ) Wnnen PolICies "d procedures 10' patient l , Course content

~" shall "" developed. mlJlnta lned "d included review \I f

~ ,mplemented by the nurSing service surgical count process

ThiS regulation was nOl met as evidenced by. and RFO prevention strategies, including review of medical

Based '" Interviews aod record reviews. the I center poliCY lor ; hospital ta iled !o Iffiplement their policy '"" surgical counts and . pr~ure on counting surgical spongea when ~ ;

process for \ a Ray·Tee sponge ... retained 'n Ih. ". announcing. parasplnous muscle 01 lho sacrum 0 1 Pallent 1 documenting, and

: The patient had a proto . ..... ound ,

recovery i reconciling lucked I from an Initial surgery on 10 lrom • partial !

sponges. 'JaCfectomy 10f a sacral chOrdoma D" 10

Event was anendc:d by , pe rs i stent s acrat 'Hou nd drainage and i 73 clinicians from prolonged healing , Patient I underwen t a

Surgical Services seco nd 'i urgery o n _ I O l or wou nd

dcpanments including debfldement Patient I ', sacral wound

Surgeons, A nesthesia continued 10 have lack of healing. then. on _", • pelvIC CT scan revealed • retained •

Prov iders, Registered

gurgleal sponge Patient I under .... ent a third N urses. Regisl t:red

. livent 10 XOON1 \ ' jl 14121)1l l 25.18PM

' 111 C- " " ; "O"'G'~g" "",'m,,","' ," '"''''' ''''''' , "GN"O", fL ' (p/?-'flu

'" 1~'f'QRnc: , ~"'''''''~n. -e"tt'"'l .. ,m , ,, ~\!~" .. t " :l~noln I ~~' (;,e "cy ... rlC!' I~. "s~.":.on "fI~, =e " ~t~nll ltc", co,·" ... i<nQ I"" • .,.nq .• 's ORI. '",,,,.O 'I' ~I '!l'"l'" '1IeQultO' ~ to • • le .~ff'C ","llItO leC I.c " 10 '~e ~~ I · • . ' \. c . • ceDI 'Ot "'J<""'l I"lD"' ~' I~I ""~ '''q, il)o ·,@ a. " II lsdou",,, ~ ~ ,: 1> 1 1~1(l ",n q Ih" :1;1 11

, '''~,O; ; ,, ~elr.e r"1' ,,~, • ~ ." ,)/ : 0""::1:0" • ~ ' o~oce a ;~. NJ!U'~ ~OtT'e l m it Jt><:~" ' '''.iI''' ' ' " '' o ,,,r l'" ~O"~"O~ " f d ·\Q<)Ul;le , ~ 1. '. \ I".,.,.,. '><,!

~~ . : ,,~ '~'l" 'UC~I"""" ~ '" ... ,;'" .. , . l~'" III .~~ '''' -'I'' 1 ; ..• ~ t ~C "," ,'f' :,'~" ,,,, J~O'oJ .eJ. ~" _ .. ;"'~:'"_ r' , ~d .. -'''~.~ ..... , ".",<1 ~ '''1'·''''

,'" .

",Ii _if'(")t·' N'" H~Allij .. ND HIJr,lAN ci!.:RvICES ,\(,!:Nt: r

uEPJ..R r~IEN r OF f'U lJlIC IlEAL Ii-!

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CADEPTOFPUBUC~ ~-::-~: -,

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'" ""IoIE o t I'HOVIOU~ (" II S\JJ' P!.IER

KAISER fOUNDATION HOSPITAL · SOUTH SAN

FRANCISCO

;;1REET .lOOllrSS. CITY STATE .:'PC OO£ SAN F " .... . 1200 EL CAMINO REAL, SOUTH SAN FRANCISCO. CA 94~~ll£O COUNTY

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Continued From page 5

surgery on _1 to remove the retained ~ay· Tee sponge whiCh was Ihe cause of the persistent non-heating wound fOf over a SIX

: month period

· · Findings:

Review of the Discharge Summaries dated ; _ 0 showed Patient 1 wall admitted 10 the I

hospnal on ~10 lor parl lal sacrectomy 01 a sacral chordoma. a rare malignanl tumor Ihal usually OCCult In Ihe spine or Ihe bate 01 Ihe \ kull Addllional diagnoses of Ihe palient ; Included diabetes and hairy cell leukemia . t

, The pallent loleraled the procedure well and i · was lhscnargad o~o ,

Fur1her record reVieW showed Surgeon \'s ' documentation on Ine History and Physical I Note d aled _ 10 th ai slated , "( T he patlenlJ has been recovering slowly but slill has ' two small areas of clear/pinkish drainage. tTne ' patlent)del118S any fevers , chills. nausea . I

vomiting I The pahen t) nas been dealing wllh I bow&! and bladder Issues and these seem to ' be Improving sleadily Giyen Ihe perSistent i drainage. tthe patient) 'S here for evaluatIon ' and diSCUSS ion 0 1 ' .... ound oebfldemenl ..

Subsequantly. Patlenl I underwent a second

However, an MRI

Ihe recordS showed 01 Ihe pelvis was

IncISion 00'

thai .PO _ 11 : dona 10 lurlher i

ayaluale the area of the ongOll1g. non-healing

Evenl ,0 XOONII }/ 14/2011

""': l{!l A'S p, ,,~ ,)I" C:': f;;n l t: liON

,I ,.~ .. CQHH~( " ~I . ':'11". /. ~)+OvI,[) ' II ' : Il(j'.>~·

,(I " ~ ~n>c(o '" ' ,.;t- .v; "01"". -I [}l ' ~:~-,.,,:,

225 18PM

Nurse First Assislllnts. Surgical Assistants, and Surgical Technologists from the Operating Room: as well as stafT from mher procedura l areas.

Agenda topics included rationale for surgical counts: responsible parties in process: strategies for minimizing disruptions Ilnd errors related to human fac tors: sequencing of count Ileti ... ;ties in relation to surgical cnse now I events: re ... ;ew of items 10 be cotlnt«i: step-by­stcp instructional re ... icw lor each category of counted items lsponges . needles / instruments I: process for investigation and resQlution o f discrepancies.

- Hi!,;hly Rl!liabk Surgical Teams Suq~ical Sat~t)' Summit curriculum materials \H're widt'ly distributed to rh ~(-~icia ns and ~tatl

I :,SO~A rORY e ,REe TOR., ;;R PFlO'lIOf.H,$UPPl IEFI "IEPf'lESEN fA fiVE S SIGN" rURE II HE . ~, - '\' (

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I)EP!.l~ f I,IEN r OF PUBLlC HEAL Iii CA DEPT OF PUBUC HEAUH

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1' 4, ~ ; UM"""'~V ~l A fl ... ENT Of ct ' IC'~ N<: \lS 0 , "QVlD ~II 'S PlAN I)f CORR~C 'ICN ' "

Hltr c~ ! .o,c ·, OlfICI[tK: Y MV,;T liE PIlf..C rEC~ D 9'1' f ULL ' ''(FIX ,r AC I'< CCP~Ecnve At "ON S!10ULO a~ ':"'0 '>.:1 , C 'APH~" OM:; ! C UlA1Q IIY e R l S{; ~O£Nllfy lWI tN(1)II>Ml I0N I "0 l'lHIIENCEO fI) W f. foP" RDI'II .... r£ Cf.F'CLU,CV, ' .>.a

Continued From page 8

sac!at .... ound. The findmgs '" 'he r&por1 ! working in surgical and ·1ocumented ,he following. "Left

, erector 'plnae procedural areas.

m U$cle 3 6 em colla chon With surrounding Monl!o rina: . Inflammation. suggestive of '" Intramuscular ' • Perioperati ve services wi ll 3171201 1 i r.lbsceslI ," Consequenllv. , CT scan 'HaS

monitor compliance with adVISed.

action plan through month ly I On -", the CT revealed ,he ,

aud its or surgical case . can sponge counts.

+ !ollowmg . 'Complex thin curvilinear density I n Sample Size:

seen ,n 'h. area 0' ,he 8)!pacted abnormalrtv 01 . Random Audit 50

th. to. erector spinae musculature mOl' i ~asesl month

suggestive 0' retained spongs 01 packing I Required , 0

, melenal " , Compliance: 100% ,

Patient , underwent • th ird surgery on compliance w ith

-" ' 0 remove ,he rsta lned sponge expected process

Surgeon " , report d ated _" for 4 consecutive

documented 'he follOWing, "The patient ."' months. , , Petioperalive July 201 1 ! brought " urgently 'Of 6valuallon, I '". 'he

Services Director patient th is morning , nd diScussed the · will submit rcpon siluaUO" With " he patient). , ad ... ised ithe '

pallenl) '0 urgentty 90 '0 ,he operating room . 10 Risk & Salety ,,, removal of 'hiS 10I"61gn body this was , Committee. ..

ma, " ' ho source of IIhe pauent's\ nonheallng I Qua lity

wound." "

'ho same report, Surgeon , Improvement

described ,h, removal of 'he sponge " I Commillee and

follows: 'A probe .'" placed Into ,h, sinus and I ,"Iedical Executive

after w, 90' Into 'he subcutaneous tissues. .e Committee.

cutdown 01'110 ,h. probe. ThiS probe tracked down '1'110 • caVity wtHCh ." " the le ft 1 Audit Process Indis:ato~ include : parasplnous muscle dn8c1ly where , reta ined Adherence to

Ray· Tee 'Nas located rhe retalnEtd Ray·Tee ' policy fo r initia l

was to , 'Nalled off cavity ThiS was extracted and subsequcnl readily " ' ponge ' nec!Jlc

iustrum!.!n! count.;;

Event lO XOON11 ,}/ 14fZ0 11 , ~ 25 18PM

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CA DEPT OF PUBLIC HEALTH

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A ",U;LOIN\;

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'IAM( O~ PNt)IHOtN t)A SVf' ''lIER ~T"F.H " OOIlUS CITV s-r.rE 1./P t;ODE >;AN l;v

KAISER FOUNDATION HOSPITAL· SOUTH SAN 1200 EL CAMINO REAL. SOUTH SAN FRANCISCO, CA uoao SAN MATEO COUNTY FRANCISCO

I,' 41 00 \J~MolRY S TArU'~N l Of'DEfICIENCIES " I FlovICE~ 'S PLA.N C ~ CUf;REcr'Ck , .. , HIHI~ ' .. ... Ii o)tf ICI~ "C ¥ MlJSII'I& P"'H:f f.Cf.D BY ! \.IlL "lH~ " ... eli CO'HI~C""( ~cnON ...... CUl O Af CAG';!>. f; 'l'·U ' I

1",,, 'FOIJlAIQRY 1)111 sc 'OENnFYI'IG It-lf'OI>IAAT<CN' -,c- " t ~F."nICEO 10 riot . ~' ~"(lP"""IF r.H "'IENC~' . Continued From plge 7

. On • sublequent VISit 10 Ih. hospltat beginning ! , Use of sponge ." during ,n interview " 11 ·36AM, ' coum bags to Circulallng Nurse 1, who was present dUring I display discarded .h. .,0 surgery, remembered Patient 1'1 ..pongcs; case ,." wet!, Circulating Nurse 1 stated, "(It) ., Circu lating Nurse ' was • lu",", case ... il fairly b~ "' .. lalting ! maintenance of the I approKlmately 3 hourl, .. lIhe tumor) •

white board with 2'0 was l deep in • ho spine .. there we • • 10. 01 bleeding I ,

count data; • nd , 101 of spongel being uled .. it was no • . , , Use ofapprovt!d crisiS Situation,. it w., rouUne bul thera 'Nere . process for

' more Instrument! u".o than usual." Wh.n lh,s i resolution o f 3ufveyor Billed ClrclJlal ing Nur!Q 1 about , discrepant counts; surgical sponge counting practice. .h. nUr5e : 0 fht Surgeon calls responded. ·'The counl5 ". re«)(ded on .ho I - out each and every count boilrd There " .ho initial count, closing ' tucked sponge: count, ,nd tinal co'ml. Th. final count " .' Circulating Nurse .. mnounced '0 .h. surgeon." This surveyor, documents tucked .'Isked what SIJrgeon 1 customarily doe, when ! sponges on the , .h. flnat cOIJnt " announced .nd .h. nurse I board in the area

, res!1onded, ·'Not sure it h. visualizel but he identificd rOr acknowle<lges .h. teilm when .h. final count " tracking l ucked annOUf\Ced, ~ Then, Circulating Nurse t wat ' sponges: asked

" .he remembered whether 0' no. euse Conclusion 1

Surgeon 1 announced that hO d~ • deep Final Verification i sponge luok during the _ 0 procedure .nd

aCli ... ilies. inclut.ling , she stated, "I do remember Surgeon t did l

passing of a ll "01 annolJnce , deep luck sponge. ii ' sponges orr

, remember) the,.. w", no tuck recorded on the l surgical field for , board There i, , special section on .h. count

,·cr i fica t ion by tho: ; board speclficalty to, deep tuckl. Tho practice '

~urgeon;

" that Ih. surgeon announces Ih. deep tuck " , R.:moval of all Cllculatlng NIJrse 1 was confident that 'h. r'nal ,

liners from all USt:J I count was correct. "We did Ih. clOSIng . kick huckets b)' t he together. w. did 'h. bags " • team, ,nd

<; lI r~icli t Scrub tlefore the pahenlleft the room, I was contidenl

( venl lO XOON1 1 , ~ 25 18PIA

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_ALlI-, ,HNIA IIE;~L -IH AND HI)MAN SI:HV!CE~ j ,dt:N(,Y

vEPAR1MENT CF PUBLIC Ht::AL l'H

. t,\TfMtONT fl. 0 ' f.c'UICII:S ,.t l ) ~ " OV'OlR.SlJI"'llt. fl'ICL""

.~ f',:'fc(.,., ~~1" "'J ~llfl>

CA DEPT OF PUBLIC HEALTH

AUG 1 3 201 '<j,i1~ " .... ,'" [6"'" """'""

050010

, Ul.ifI.OIUG

rt '1I.1t-1G

'~#Pll If 0 ~~- ,

18 C OMSlO' ~ ! '·0313012011

N"'ME 01' ""ov..o~ R OR ~uPpt '~R ;; fl!f l l AOORESS, CITY H~ r" liP r.OOE SAN I<AISER FOUNDATION HOSPtT AL • SOUTH SAN

FRANCISCO

1200 EL CAMINO REAL, SOUTH SAN FRANCISCO, CA 94080 SAN MATEO COUNTY

, ,.,1\)

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" ,,"WR> S1 '" t~M~ .. T ')f OH l(;lt"'CIfS I 1.";1' ' IH,':" t.C V 'jU~ T Il~ ... R~~UOl 0 II .. HILl I c:o;v.. r r.flY fiR l~;C ICF. JoI T'f "'w.> ~lfOfl """ l 'ONI

Continued From page a

the count was correct.·

l in another HlteIV!eW on 3128111 at 223 PM. ! Circ~ Nurse 2 was also pruenl dUring i

, the _ ,0 surgery but was the rehef nurse lor t lunch break for Circulating Nurse 1 so she was , not lIwolved In Ihe final sponge count but she I

did acknowledge that surgeons customarJly ! announce ' Ieep tuck sponges and the I circulatIng nurse would record the deep tuck i sponge on the board. Circulating Nurse 2 ; l ISted. ··Somehmel surgeons don't announce j

removal of me deep l uck sponges and (when ! thai hAppens/ I <lsk the surgeon II the tuck :

'iponge was oul"

In Cln Interview on ) 12911 181 12 -21 PM. Surgical SGIUO reChnlGlan 2 \Surgical Scrub i roch 2 was diiO prelent r.!unng the ..,o I surgefV Out Nas the lunch Oreak rehel for I Surg ical rechOlCllJn I so she was not 'nvolved i In the tlnal sponge count p roc$u),$h$ I acknowledged that In general, surgeons "Iell I the scrub t abou! the deep tudl sponge) at'ld i the scrub ...... 11 communicate this to the j

Clrculallng nurse .,11 the lucked sponge ..... as 1'1 01 ,

announced, It Wi ll show in the tinal count."

, During " Interview '" ]129/1 1 at 335 PM,

Surgeon t stated that ,he pallenl hod "wound

break down. 0. • sllghl opening '" ". surgical

wound 51 \9 altel ", lirst sUl gery/" The

treatmenl " that I,me Involved home wound

managemenl 900 dose observauon OUI "he I wound did 1'101 completely heat ·'

f -.lentil) XOON I' ,,1141201 1

. ';':;vlllHrs I'lM' '" ';I)I>RfCTIOh ~AC" cell IU'C 'I'fE .o ,; I'I) N !.iHI)\.'i. C ae CIOCSS 'f) ' <I I NCEO I I) l ltf "'f'''~GI'II'''lr £: [F '(; Of ' j(: "t ,

2 25 II~PM

Person t R N or technician).

C leaning Procedure: In­Depth for OR Suite iTcmlinal) (Section 4F) has he!!n revi!.ed to ilddress specifically hnw the kick buckets will be handled between ca~cs.

R~sponsible Partie!!: • Periopcralive Ser.icC!s

Din.'Clor:

• Chie f Nursing onictr:Chief ()pernting ()fficer:

• ,\ssistanr Physician·in·Chicf ll fOperaling Room;

• Physician OR Director

•

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t..H'AR r W ;: N I Uf l ' lItRU.': HEAL I Ii CA DEPT OF PUBLIC HEALTH

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'1.o\ME OJ. ,'1I0VIOf_R OR '>UPl'l" II iTIIHT ' OCllfSS (;1 1'1 ~ r~ 1t .',~ ((;0£ SAN FAAt~CISCO KAISER FOUNOA nON HOSPITAL · SOUTH SAN IZOO EL CAMINO REAL. SOUTH SAN FRANCISCO. CA 94080 SAN MATEO COUNTY

fRANCISCO

I'. ) D i \.IMlMIOY ~ IA'fMfNl Of c·!'., I Clt 'IC'~S " I'C"CfI' ~ "U,"I ;~r ': )'''' ~ C f ON " 11 1._ , "CI I Ct. . 'l- r(NC ', 'A',:.I lIl. 1-'f' 1' ;:'£f CI.C (1'( f lJl l " n:~ l"C" ~()J!Qt:C 11' I, Jo.r. 1 " )1' , 11, .1.1<.:: fIf. U'':; ,:;.

J.\\.> 1 1' ,,1,1. TC"V ol io! 15C otFt.n ~....:'. ,jl/:,'MAr .. ")N, - 'I.> Hf.II{;I.Cr.D of"; ' ''l n l """r."",, rf rot " (;1( 11, . ,

Continued From page 9

According '0 Surgeon 1 dUring the 1ame fhi s pllge illlemiona lly len blank

IntervieW 0' 3129111 . 'h. second surgery

rellealed necrotiC linue which h. believed was I

,h. cause of 'no non -healing wound. But. even i atler 'h. ,.,,,,",, surgery. Surgeon I stated. i "the wound broke d~' again ~ Surgeon , , thoughl 'he patlenl's hIStOry of diabetes and I

I leukemia mlQht have been conlrlbulil"lg factors ,

. '0 'h • per1lstent non· heallng Nound The :

surgeon slated. ." contulted With ,he Infechous

Disease f,lhyIICI 31"1. treated the pauenl Nllh

:Inllblotl ";s <lnd managed IIhe patlel"l\)

COnSef\'3uvely " , , DUlong "'. mler /lew COI\ductetd on jl29 l l1 at

335 PM , ~urgeon 1 spoke 0' his analySIS of ,no Inlhal surgery on . '0 "The wound was I

, deep there w .. an ,ncreased amount 0 1 :

. bteeding of "'''' ,

'0 the,e were 1015 sponges ! , I the retained sponge ... on !h. parasPlnous i

muscle which ;, '" area no' .. '" Visible .I I relied 0' !he count.. '.IIhen 'he count was !

-stated t;Ouectly, , agreed - Whon IhlS i I surveyor nked ,he ~ urgeol"l legardlng deeply !

tucked sponges dUfing surgery . he replied, ,

Ray,Tees. I like ;

"Personally, , don·t like '0 u'" '0 u'" ", .. ponges \laparotomy sponges) 'n this case. , needed '0 "" ,he Ray·Tec '0 mo .. ,h. muscles .. When thiS .. urveyor asked ,he

surgeor'l "

"- could fllmember whether 0' no,

he i1nnQul"lced • 1eep lUCk sponge, "' replied.

" don't remember ,f , ''"" Finally. Surgeon , stated that ,no last ume h. spoke With PaMnt , WBS on _ II At that time, the wound '\"as

~ ~t:f1I ID :.tOONll ;st 14120 11 Z 25 16PM

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KAISER FOUNDATION HOSPfTAL - SOUTH SAN 1200 El CAMI NO REAL. SOUTH SAN FRANCISCO. CA 'HOllO SAN MA TEO COUNTY FRANCISCO

" "'I(l , ' /MAIIY ', TMI MfP<' Ot IJ! I "':, N<;jES ,e , "O~)CLH'S Pl "N (.:1 ':O!lPtoCTION ' PHI ' , A':" Illl'OCll t~;) '.IIJ ~T H ~"H': L ~ClO!lY ~ lILl ';'HI> I .• C, ' ';:Oll "£."; r" ,,~ Mc rlrJN S"CUl.ll ll~ t:H()!t'l. TM~. '" ';UU<IOIiY i)ll l " ,~ IOf l'l T!f • "1(\ 'tj~OR",,'flml\ '" G , ~'I ~j f Hr;NC[O TO r,,( .'~'W(".J-"'A If Ctl., · t~W;Y ,

Continued From pag', 10

down to 1 em and was now healing well ~

Duong • lelephone IOtervlew 00 3/30/1 1 al rhis page intentionally lell blnnk 10.30 AM. Nlth Surgical Technician

" Ihe I

, surveyor asked ,I he recalled 1M case Ihat onvolved Palienl 10n ~O H. said , ·'1 don', i lemember lhe case b", 1M "me sounds 'amiliar.- H. atlo stated. ~Surgeons mosl 01 1

.the Ume Wilt announce deep tuck sponges and I that 'h. scrub 'e'" w,' tell 'he circulating who I

Cf>. QEPi Or PUBLIC HE/lLiH records 0 0 ". bOard " His owo personal I practice w"' he made • ,nark 00 'he mayo I 5tand wllh • marker when • deep '"'" occurred I

" 0 help him keep !rack. Th. surveyor asked AUG 1 3 20\2 what Surgeon 1 customarily d~ " 'he "nal .

I counl dnd h. 5&110. 0 He verbally 3cknowledges

U.C O\'JimO!'t -.... hen 'he learn "nnounces 'he final CaUl'll " , SAN FAANCiSCO cOllect ,"d Ihal ,Surgeon " Visualizes the ,

, blue count bag."

Dunnq '" Inlervl(lW 00 Ji291t 1 al ) ' 10 PM. the I Director 0 1 Risk Managemenl Slated thai the 1 'aGility reViewed "'0 case w tlh Surgeon , Circulehng Nurse , ,"d thO Penoperallve Service lone Direclor '" - 2011 after

'he RFO incident w" diSCovered ,,'d revealed

ihe follow,ng I )Surgeon , 1 did recall 'he deep I , sponge luck ,"d Ihat

" • n • bloody case .

21The documenlabon was correct 'egal d'"g , , ,

'he s ponge counts J )The ,n terna l

IOv8Sl1gai lOn could 00' def'nl t!llely dete'ffilOe the cause 01 the RFO

Dunng 1M same interview With 'ho 'he Director

of Risk Managemenl on 31291 1 I she slated

.

'y I"'!(I~"C ~ iWle enl < ~,nQ .• ,\~ 3n :!.j'e",. " 'e"I>IC' a "~l 'C,e" c •. ,·",t~ 11 '0 ,"'IO!~UCO rr .. ~ ,,~~. c,",\ ed "~m C¢" i'~" n<l ~(O. _HfQ "\ , .. ,. ".\~ , .. <l

" .11 c "' ~' . ~teQUdIQ' co,,," ' .. ' IJ"'CI"~I ~,c"c""" to I~. O"" .. ~I' ( ·ce['110' "U ' ''~ Q ~ O'T'el '~ I! f",~ ,n1' 400, ,, WI " ' .. ckl.~ oi" ~~ ua •• ","0 .. ."., .... ,e Ut~

~ I-.r.". ""~ ",,.,. ,,0<), J Ol ~" '" to<l<!<t ...... '. "'." ' Ieo O' .,,,"""~ ,,~ • .,., . '~ • . II>()', '! · ~.l l ·"'$ ~,,~ ~;.,n , .,t tC"e<:tlO<l ,," 'I '. c'o'~t'e \4 .:I I .' '''''0''' 'wI

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:)EP'".R H.tEN r OF puoue HEAl. rH

~"n..u '-If 0 1 LJ(FICHI-: lS 1.< , . ' · ''') ''rOt!lIhiVI; I'l'E ~'{:ttA

~1I0 . "tft.N .~ , .:CH"~C11'"J 1'i ,~ l Nflr ~;.'h;1i '''JMlOI::ll • 'II • ... JLTln~ ;;~"ST Puo.: ! ~U , ~,r ·' " ,'_II"t~

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~ 050010 It V/;NG 03/30/2011

1110 ""; .Jf I'IIO'lILX II ClH ~;!Jf'''lIf M ~ rllnT IIOOIIESS. Clry 'irA'I': : '" COLl E

KAISER fOUNDA TION HOSPITAL - SOUlH SAN 1200 EL CAMINO REAL. SOUTH SAN fRANCISCO. CA 94080 SAN MATEO COUNTY

FRANCISCO

. "."U , " MtAAII1 ,, ! ~ r''''l N r i}l- l ' l f !C'P": 'E 5 ." "r; IIlJtl" o; 1~ ~N ·::; r r: '~" I C. nell

·l.(Hr' , ~,;" (:11 "" NC> 'A\J!,r HE 1·"'.ClU:t!llfr nJll "1 ' I~ , ... ~,., e.C" ~c 'NI <'. t .j .. ·" '· )IJ. L' !l . .. 1) , -G ., , .lA" T r:H~ <J ~' ~c ,cn,'" ' 1' 1(, "" ~fI ''''' l1CI') "''' , "il! ,:'I".fO T"· ..... ~ ",.o·,,·~ r ','."':_ '. •

ConHnued From page 11

Ihal '" facilely'! RCA formulaled possible

':3uses 0' <he RFO I)There mKJhl have been . . , ,ponge 'e. " , .. k.k bucket Ifom • priof ~ pfocedure. 2)Not '" deep lucK! were I

, . announced b, surgeons unlen thefe Nere \ cavities Involved Announcement of • deep I , ,

i tuck sponge b, surgeons w" done mainly wIth 1 ! procedures that Involved cavlt ie!. 3)The blue

I hotder bag! overlapped e8ch other when hung 1 ,

on Ihe stand .

Ihe tlosoltars policy ",d procedure utled. Title 22 Nursing Service Policie!l and "Surgical Counts 1 Sponge, Needle. Instrument), ' Procedures: Number PC 19 11 . il ffective date 4 /1985 .

,avlew/revlse ·1ate 0612009 documented 'M In response to th i s event Kaiser Fuundat ion follow,ng "page ,

~ 4 1 lie-tTl! .... n'ch h;}vlI been I H ospital South San Francisco is laking Iht! lucked Inlo <he wound or whIch cannot be ; opponunily 10 furthe r review our Surgica l '~i:sua tty accoumed lor do. '0 their being '" use , Cnunt Policy tu make I.:hanges for tunhcr

" thaI ume WIll be verbally accounted for on ! d ar ity.

'M count board. ,,'" Ih'5 ,"formation reviewed ,

b, Ihe 'ncomlng .n' oulgo.ng parties . page 6

4 .1 Any Item lIlat i, lucked or packed into Ihe ,

i 'HOund, or caVIty , Genal, orifice le_9 . throat I

packing, nasal ~ vaginal, etc) w.1I b. verbally CA DEPT OF PUBliC HEALTH announced b, <he Scrub Person " ,he ,,~

"

" ,"selled InlO <he pallent, ,nd documented on

Ihe count \)Card " Ihe C,fculating Nurse

LIKew ise, wl'len .n >Iem preVIOusly documented AUG 1 3 20\2 .. being tucked or packed '. removed from Ihe '

patient, 'I N III be croned 0' of Ihe '"Tucked l&C D!V; ::} (()~~

Hems" count " SAN FRANC/.~-;GO

Th e hOS Pi ta l's policy .n' procedU f e

Iltled."Cleaning Procedure - t3. In· Depth Fo, " SUlta (Terminal\. alfechve data 111985,

.. S::vellt 10 XOONll ')1 14/20 1 I 'I. '1.5 ' 8PM

~ , ,or!lG"'I>C' ".'Il' ... e ~'·l'f''''''l ft·."., ,,' 1l!""" " ~'!~'\!'. ~""C"'''~Y "r;l' :n" (liUlu"or "'." '''' .... ,,,, .. <1 hen, ~O"fCIA'<) ~ 'O .. oJ "~ ,I 'J.""~>f'''C ' ., ~'~I!' U letjU"'H :" •• o •• " 01" . .., ,,. OI'" ' .... ~u,,.., 'I>. L ~'.l!nlS L.~e-c' ' 0)1 ~""~·9 ~oml!' ,"" ''- ''''''J' . ".," I! JJ" ~ ,1t1C 1lI!H * 'n. '" co ... ,nq 'r~ ; .'" f ,~t .~, '"'''e'''''' .,. rOl • "." ~I :""~'oC(I "i ~-." teO " , ''' ' ' '- 'j ' ''''''n '''I! ~ t<:~ 1! • ~'l ~'l ' "'" , ·j.,r, )t ~o::" e<:',o" "~ '''~'CH :>l1! .• : .1'0 0 !"Ue-., "'1

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J,Llf Gt.N11' Ht: i',L II t ANO HUt,1AN .::.1:JNICES AGENCY

' ) tPAf~ I ME-NT OF PUBLIC HEAL l H

;IAf~ 1,'1 'II oj , Ol l lCtnlC F.S '~1\. "c~".a"·lolJ"f"!Ef>X: l"" .. tID f'V II Of :';011<>1 (;I"'~ " ., ill 1(;,\ '0(:/1 '~'I,\IjE"

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,"'''* 01- I'IIOVN}HI OR SUf'Plft' R ; 'iEi r ->Ct'l>I !iS <: lTV S· .... " /II'r: <;;-af

KAISER FOUNO" liON HOSPITAL · SOUTH SAN 1200 EL CAMINO REAL. SOUTH SAN FRANCISCO. CA 94080 SAN MA rEO COUNTY

FRANCISCO

, , OJ II) , 'JI.4IAA R~ STUUJHH 0:':' ct'.r '('Hf\:tl:S , , I; ,-;',lO~FI 'S ' '\.JoN ~;, '; G ~ "FC T:(\,. " "n,~ i I ' 1;;< I;H I~;IHiC'( "'UST HI' l' ''I·CF.I.01:0 11'( HilL ' ~U ') -.'_"'H t;D nH IiC1 IV~ At r,1):1 -;Ht)'llC Af Cf'OloS· -; '-'I' U I, J ~ H , · I'GUI ,\,1)11< 0 " l ~C 10 1 NT ,.. 'l' lG .!'IFOP W TOC I'II .," , ~ flEf>fNr.fO TO T"F . ""'''01'1'1/\ If to <,:1~ No;'" \' 1

· Contlnuld From page 12 ,

· revi$IOo date 312712009, documaoled Ih e This pag\! irttcntionally len b lan\.;

fonowing ' 'page 2 of 2. Procedure ·Daily. .. · O perating Rooms . W ash w ith approved

I germICidal solution _II fhtlures . equipment.

furnit u re rho r o ugh ly 'N ash ..... as t e

l eceptacles . rho Perloperatlve ServIce Line

Director staled thai lhls poliq addresses ,h.

EnvIronmental ServIces' tesponSibili ty Wl lh '" , clean "" of ". "" buckels when h. gave thIS

document '0 this surveyor on J/30111 The !

documenl does MI address how "'. ,<, buc kets should b. spe cI fi c ally h andled .

berween O3ses.

Th. hospital failed '0 Implement thetr poticy CA DEPT OF PUBLIC HEALTH ilnd J:rocedure '0. , urgleal sponge eOllnl when

- Ray· Tec 'Spor.ge w .. retained '" tM left

parasp,nous muscle 0' "'. sacrum of Pall.,nt t

during 'lurgefY on _ 10 He underwent a ' AUG 1 3 20 12 second surgery on " 0 for wound debrIdement ,," a third surgery Qn .1 lor LP.(; OIVi'.:iGN removal of "'. retained surgical sponga . TIl.

SAN FRANCISCO spo nge wa, reta ln@d fOf over 6 months an" a" • result. the patienfs 'Hound 'tom "'. original , surgery "'" delayed heahng. Surgeon 1

missed tho count during surgery on ~o. 1 then missed the oppor1untly to discover the

R FO .t "'. post -operatlVe '/iM 00 _0

Nhen h' delermlned only adeblldement ... req ui red By limiting ,I " eKam lnat lon to , diagnOSIs and treatment 01 fIle ,nfection .vllhout

proDlng lunher to determine !he ,:ause .

Surgeon 1 may have fur1her delayed the ,

discovery 01 "'e RFO. Delayed dIscovery 0' "', cause 01 the non.healing wound did nOI occur

, veil! 10 :-; OON11 jJ 141201 ! 1251 8PM

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,~I H"'Jh' t ll '\ IIF!\!. III ANO HUIAAN SE.RV1C~S i,, ~ ENt.: "

.JEP,\~ 11,IEN I l;F PUULlC l-Il:Al IH -

\1"'" ~II-NT 1)1. rn 1"I':/[NC. .t5 I "t I'>Hl'i1l11 ~S\.'f'Pl.l;:N<'~l'" •..• ~ 't'A "1 It (.r .. . ,o.!Il',<,:~ ,.~", • .-::~ T ~ " ; 11,,

~ .. u ' ;'>1 rji f:nfiRI: Cnt;l h 01 I ~I r ,t ~~,' l KIN tlU .... l~,. • .'~. , " I

• "'."ce 11(,

h 1)50070 il ,.'''!.! 03/30lZ011

~ 1,)1 t-~o-.IUE /ol OR <;UPPLIEH ~ m EEl _' UOPES! c ;n l:i ''''E ZIP ':;C CE

KAISER FOUND" TION HOSPITAL · SOUTH SAN 1200 EL CAMINO REAL, SOUTH SAN FRANCISCO. CA 94080 SAN MATEO COUNTY

FRANCISCO

t ' ~ I ,,) ,lJf~WIW Sl Alf.MUIT or DE f '';llOfC:(! , '-/lO'." O('I'I'5;ov. .. or ';CII"~C nCN

"1I1 1 '~ , Jo.,:H UI::I I!;IUM:~ .... UST Ill' P RIi CEEDED BV f 'JU "'I roo I "';H CCR"~CT'VE "C'K)~I ~ HOV~il e~ c .. c~s N, , . 1 CUlA lOllY r.R I.:';C oOH. TLF~I ~IO II I ~OP",U n CNI ,,,. , ' I-f[REHC~O 10 • ,·r .H".'\P ...... I ~ CF~ ·C ._'I": .. .

Continued From page 13

UI1t1. 11 which suggests thai trealment '0' This page inlenlionaily len blank ,h. Infection may nave masked 'h. effects 01 !ne RFO by prevenling a full blown ,nfection

I despite the presence of the RFO, i , This fa.lure f, a deliciency thai ha, causea, 0' '

" likely '0 cause, serious injury 01 death '0 the ! pallenl. .nd therefore constitutes .n Immediate !

leopardy Within 'he me811lng 01 Health and 1 , Safety Code Section 128O,'

This racilily failed " prevenl 'he IJeficiency t.es)

:15 desCfi~ above that caused, 0' " likely '0 cause , serious ,nJury 0' death '0 "'" pattent

and therefore constitutes " Immediate

leopard" within 'h. meaning 01 Heitllh , nd CA DEPT OF PUBLIC HEALTH

0 Safety Code Sechon t 280 lIe)

I AUG 1 3 1011

L&CDIWm N SAN FRANCISCO ,

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t-venl10 XOON l l 'j, 141:10 11 , ~2S1aPM

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