Hospital Cited for "Serious Events"

By Walter F. Roche Jr.

A small rural Pennsylvania hospital has been cited for failing to promptly and properly report serious events involving the care provided to three separate patients.
The recently released report cites the Endless Mountains Health System in Montrose for failing to report serious events to the state Health Department and the Patient Safety Reporting System. Hospital officials told state surveyors that their colleagues didn't think the incidents met the definition of a serious event.
The surveyors were at the hospital to determine whether it complied with the minimum standards for participation in the federally funded Medicare and Medicaid programs.
According to the report a serious event is "an event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient."
Loren Stone, chief executive officer for the health system said, the cases cited by the state Health Department, were, in fact, submitted correctly under the criteria set by the state Patient Safety Authority.
"Endless Mountain Health maintains that they were correctly classified under the Patient Safety Authority guidance and algorithm," he wrote in an email response to questions.
The first case cited in the state report was that of a patient who underwent a CAT scan with a contrast agent. The patient suffered a rash over the entire body due to an allergic reaction to the contrast and had to be treated with Benadryl and other drugs.
The second patient was in the facility for hysterectomy but had to be returned to the operating room due to post-operative bleeding.
The third case involved a patient who was treated for severe pain with a morphine drip. The patient began shaking within 10 minutes of the treatment and was treated with Benadryl and Pepcid.
The hospital filed a plan of correction in which it promised to re-train staff on what constitutes a serious event. The plan also calls for an auditing system to monitor all incidents to ensure they are being properly reported.
The report also faults the hospital for failing to perform annual performance reviews on three certified nurse anesthetists.
In addition a review of records showed staffers failed to perform pain assessments on five patients following the administration of pain medications and before their discharge.
Stone said that the hospital submitted a plan of correction that had been accepted and implemented.
In a final item the state surveyors faulted the hospital for the failure of a member to attend a meeting of the infection control committee. The same finding was included in a prior report on the same facility.
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