New State Hospital Inspection Reports Available On C-HIT

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Various violations that jeopardized patient safety, including several before and after a newborn died, have taken place in Connecticut hospitals, according to the most recent hospital inspection reports from the Department of Public Health (DPH).

The reports, which can be found in C-HIT’s Data Mine section, cover inspections that took place at hospitals between 2016 and first few months of 2017. Some of the violations resulted in injuries to patients, while others showed lapses in infection control standards and other protocols.

The Hospital of Central Connecticut in New Britain was cited for several violations that preceded a newborn’s death in 2016. DPH found several errors were made during and after the baby’s birth. Among them, staff confused the baby’s and mother’s heartbeats; oxygen was ordered for the mother during labor but was not administered; and a Caesarean section was performed an hour later than a physician would have preferred, after the use of forceps was attempted and failed, the inspection report said. The baby was born in critical condition and died about 20 days later.

Also at the Hospital of Central Connecticut, an anesthesiologist performed a hip nerve block on the wrong side of a patient, though the error was noticed before the patient underwent surgery; a radiologist removed fluid from the wrong side of a patient’s chest; and a colonoscopy pouch was sewn to the wrong part of a patient’s colon. Separately, a drain broke and was left inside a patient, according to the inspection report.

Other significant findings include errors made at Saint Francis Hospital and Medical Center in Hartford. In one instance, a tool known as a snap was left in a patient’s chest after coronary bypass surgery. In another case, a physician inserting a pacemaker in a patient noticed a guide wire was “floating” near the patient’s right atrium but later forgot about it and left it in the patient, according to DPH.

Also at the hospital, a central line was incorrectly placed in a patient’s artery rather than a vein, which has to be fixed surgically. Separately, a patient admitted for a colonoscopy and upper GI endoscopy incorrectly underwent an esophageal dilatation that was intended for another patient, after staff failed to perform a “time out” in between the procedures, the inspection report said.

At Bridgeport Hospital, a newborn fell from a bassinet while being transported by a registered nurse. According to DPH, a nurse moving a baby from the labor and delivery area to the newborn nursery held the upper plastic portion of the bassinet rather than the lower metal part. The nurse’s foot hooked onto the bottom of the crib, causing the infant to fall to the ground. The baby was examined and found to have no injuries.

Also at Bridgeport hospital, a piece of a surgical sponge was left in a patient’s vaginal canal after a hysterectomy surgery. The sponge wasn’t found until the patient came to the emergency department several months after the surgery, complaining of vaginal bleeding that lasted several weeks, DPH reported.

At Bristol Hospital, a patient about to have cataract surgery incorrectly had an anesthesia block performed on the wrong eye. The surgeon and patient were immediately notified and the surgery was rescheduled.

The DPH generally surveys Connecticut hospitals every two to four years. During the unannounced visits, inspectors tour facilities, observe staff in action and examine documents. Though hospitals are surveyed every several years, DPH typically inspects them more frequently in response to complaints and investigations, according to DPH spokeswoman Maura Downes.

In response to the inspection reports, hospitals submit corrective action plans that require DPH approval.

C-HIT Writer Kate Farrish contributed to this report.

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