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EGH Reportable Adverse Events (2008)

The following two adverse events were reported to the Indiana State Department of Health. To put these events in context, there were 12,945 patients discharged from Elkhart General in 2008 with an average length of stay of 4.55 days. In 2008, EGH recorded 180,703 outpatient visits. Both discharges and outpatient visits were significantly higher in 2008 compared to 2007.

1. Surgery performed on a wrong body part (December, 2008)

A patient was admitted for a herniated disc. Prior to the surgery an x-ray was taken and the vertebrae were counted to ensure the correct location (level) of the procedure. This practice is standard policy for such a surgery. At the end of the surgery another x-ray was taken which showed the incorrect location (level) was fused. After speaking with the surgeon, the family decided to add another procedure performed on the correct location. The surgery was completed with no complications.

ACTION: A complete review of the case and discussion was conducted with the surgical team regarding the Surgical Site Verification process. It was determined that the Time-Out process was conducted with the staff according to policy. The team did determine that all appropriate processes were followed even though patient obesity created surgical challenges making it difficult to identify anatomical geography.

2. Foreign object left in a patient after surgery (April, 2008)

A colectomy was performed on a patient for colon cancer. The surgical plan was for a laparoscopic surgical approach to be used which is less invasive for the patient. The surgeon encountered heavy abdominal scarring due to prior abdominal surgeries so it was determined that the surgery needed to be converted to an open surgical case. The procedure went well and the patient was taken to recovery in good condition. Six days after the procedure the patient was not meeting the expectations for recovery therefore a CT scan was done and it revealed that a sponge was retained in the abdomen. Full disclosure was made to the family and together the family and surgeon decided to proceed with another surgery to remove the sponge in an effort to prevent an infection. The procedure was performed and the sponge was removed without complications.

ACTION: A complete review of the case was conducted and it was determined that the first sponge count was completed and documented in the medical record however a second sponge count at the end of the procedure was not documented. It was determined that the sponge count policy was unclear. It was revised to specify the sponge count procedure and when the count should occur. There was some discussion of a possible extra sponge in the manufacturers pack.