Geisinger Cited for Missed Test

By Walter F. Roche Jr.

When a patient reported to the Geisinger Wyoming Valley Medical Center for the blood test ordered by a doctor, the laboratory personnel turned the patient away, canceling the appointment. Two days later the patient was back at the hospital suffering from a stroke.
The test that wasn't completed, according to a state Health Department report, was "a test used to diagnose bleeding or clotting disorders and to monitor the treatment with blood thinning medications."
The patient's test was cancelled on June 19. The stroke came on June 21.
A review of the hospital records showed the patient arrived at the hospital emergency department "with signs and symptoms of a stroke." The patient had right vocal chord paralysis, tongue dysphagia and severe expressive aphasia.
"The facility failed to ensure a physician ordered laboratory request was completed," the report states.
"The medical test in question was submitted for instrument analysis; however, the lab result was omitted due to an isolated technical issue," a hospital spokesman said, adding that the patient was informed of the incident.
"Our patients come first at Geisinger, and we work daily to do what is best for them," the spokesman added.
The report by state surveyors who visited the 286 bed Wilkes Barre hospital in early August also cited the hospital for failing to perform a root cause analysis of the incident, a routine procedure to prevent a recurrence of medical errors.
According to the report, by the time the investigation was initiated on June 28 the history from the laboratory analyzer had been removed and "it was too late to download the files." And there was no thumb drive back up.
Surveyors interviewed other hospital employees who said the lab employee never asked for additional information needed for the investigation to continue.
The hospital filed a plan of correction with provisions for the special handling of high priority requests. The plan also includes re-education programs for staff and a series of audits to ensure proper procedures are being followed.
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