Patients weren’t told about contamination
Doctors and employees at Venice Regional Medical Center have been going through “re-education” following state inspectors' discovery that contaminated surgical instruments were used at least twice in early March and that patients weren't informed.
The hospital set up the training sessions – on both cleaning of equipment and on patients' rights – as part of a “plan of correction” to satisfy concerns of the inspectors from the Agency for Health Care Administration, AHCA documents show. The deficiencies were cleared in April after the corrective-action plan was carried out.
The investigators, who checked 10 surgical case records, found the contamination problem in two, the report says. No patients or staff members were identified.
Contaminated equipment can be deadly, said hospital consultant Peter Young, who is not connected to the case but reviewed the documents at the request of Health News Florida.
“A hospital-acquired infection generally costs in the range of $25,000 to treat,” he said. “This is a huge patient-safety issue.”
The hospital's marketing director, Jennifer Brower, pointed to a federal hospital-comparison website that shows the facility “exceeds the national benchmarks on every single surgical infection prevention measure.”
“It should be clear from these results that our primary goal is the safety and well-being of our patients..,” Brower said in an e-mail. “In this case, there were specific deficiencies cited by the state which the hospital took seriously and acted immediately to address.”
Guide pin contained 'biomatter'
The investigative report said the surgical tool – a “reamer” used for inserting a screw in a broken bone – was not properly prepared before being sent to be sterilized. A guide pin in the reamer that contained “biomatter” from a previous patient should have been removed, but wasn't, the report said.
When contamination is discovered, the normal course of events is to halt the surgery and de-contaminate the room and equipment, according to the records. The unnamed surgeon in one of the cases told AHCA reviewers that the patient was 87 and bleeding heavily, and he was afraid it would be too dangerous to put the procedure on hold for 30 to 45 minutes.
Another operating-room staff member told investigators that they were in a hurry because an emergency case was waiting for the room.
There was no indication in the report that either patient became ill as a result of the tool contamination.
But that was only part of the problem the AHCA team cited. By law, patients must be notified of “adverse incidents.”
The unidentified physician told inspectors that “he was waiting for risk management to tell him whether he should tell the patient about the incident.”
The other patient apparently found out about the problem through an anonymous call from one of the hospital employees, the record shows.
Brower said: “All physicians and associates have been re-educated on the hospital's policy on patients' rights, specifically with regard to disclosure...”
While the hospital already is a leader in patient safety, she said, “we are always prepared to improve, and we are grateful to the state's regulatory system any time it helps point out opportunities for improvement.”
Health News Florida discovered the dirty-tool complaint while checking AHCA records on another case concerning the hospital, in which officials are accused of failing to take prompt action on allegations of sexual misconduct by an employee.
The accusation that patient transporter Humberto Duval groped at least four women over two years – and that hospital officials knew about the police reports but didn't act -- appeared in a lawsuit filed this month, as reported by the Sarasota Herald-Tribune.
If the hospital knew about the complaints of molestation, it would have been required to report them to the state, AHCA spokeswoman Shelisha Coleman said. But AHCA records show no complaint of a sexual abuse incident in the 2008-10 time frame, when Duval was working at Venice Regional.
AHCA has received only one complaint about sexual molestation from Venice Regional, in January of this year, Coleman said. The alleged offender could not have been Duval, since he was in prison at the time.
The matter of whether the hospital filed appropriate reports in the Duval case is currently “under review,” Coleman said.
Brower said “all proper reporting protocols were followed regarding the alleged incidents” that involved Duval. She said she could not go into detail because of the pending lawsuit.
“Venice Regional Medical Center is committed to providing the highest quality of care and support to the patients we serve,” Brower said in an e-mail. “The hospital has policies in place to ensure the safety of our patients and takes any allegations of inappropriate conduct seriously."
Venice Regional is one of 70 hospitals owned by Naples-based Health Management Associates, according to HMA's website.
--Health News Florida is an independent online publication dedicated to journalism in the public interest. Editor Carol Gentry can be reached at 727-410-3266 or by e-mail.