Hospital inquiry in death criticized

Providence Everett Medical Center has been criticized by the state Department of Health for its investigation into the death of an emergency room patient while using a breathing mask not hooked up to an oxygen supply.

The state report says the hospital’s initial investigation could not determine if the lack of oxygen or the patient’s inability to breathe air from the room led to the patient’s subsequent heart attack.

However, the state report listed problems with the hospital’s internal investigation of the patient’s death and staff training issues.

“Lack of identification and evaluation of all factors potentially contributing to a patient’s death resulted in an incomplete investigation by the hospital,” the report says, placing all patients who received care in the hospital “at risk for repeated, similar events.”

In addition, the report said the hospital failed to assure that all nursing staff were competent in connecting the type of breathing mask used on the emergency room patient. That put patients throughout the hospital at risk of improper oxygen administration or suffocation.

The hospital now has in place a plan for how to make improvements, and will cooperate fully with the state Health Department, said Dave Brooks, the hospital’s chief operating officer.

“We consider this a significant negative incident, and the report from the state is thorough and very complete,” he said. “Our highest priority is on systemically fixing this.”

The patient was brought to the hospital by medics on Dec. 21. Hospital officials described him as “very, very ill.”

A do-not-resuscitate order was included in the patient’s medical records. He died in the emergency room after having a heart attack. Other details, such as his age and illness, were not available. The hospital said federal patient privacy laws do not allow disclosure of such facts.

The nurse who cared for the man had temporarily disconnected the man’s oxygen tube to conduct a test, hospital officials said. The firm-fitting breathing mask has two vent flaps which, when closed, prevent a patient from breathing room air that could dilute the oxygen supply.

The man was unhooked from the tube, but the vents on the mask were not opened, the state report said.

Hospital staff estimated that the man was without air “probably less than a minute,” Brooks said. “We made mistakes,” he added.

Although the hospital focuses on quality and safety, “we did not do a good job of caring for this patient.”

Hospitals are required to report to the Health Department whenever certain serious problems occur, including an unanticipated death, an infant abduction, sexual assault or rape of a patient or staff member at the hospital, and surgery performed on the wrong patient or wrong body part.

The hospital reported the emergency room case as an unanticipated death Feb. 13. The state then investigated, writing a March 31 report listing the problems it found.

The hospital has written a five-page plan on how it will correct the problems. The state agency must approve it.

“Sometimes errors occur,” Brooks said. “The issue is learning from that: how do we dissect what occurs, fix the processes, retrain staff and change protocols so that this type of incident never occurs again.”

Two of the key changes the hospital has made:

* The oxygen masks used in the hospital are now different. The new type always has a flap open to allow the patient to breathe room air.

* More than 1,000 of the hospital’s clinical staff have been trained on safety issues when using breathing masks.

The problems occurred on a day when the emergency room was operating under “code purple” conditions, meaning it was extremely busy, having no available patient beds and all available staffing on hand, according to the state report.

However, the hospital’s internal review of the case did not consider how this may have affected the patient’s care, the report says.

“What we’re stating is that not everything was looked at,” said Byron Plan, who manages the Health Department’s office of health care survey.

“You don’t know if the problem could have been corrected by a different staffing model,” or if everyone working in the emergency department was so busy that it may have contributed to the problems with the patient’s care, he said.

“In this particular case, we were not as timely or as thorough as we need to be,” Brooks said of the hospital’s initial investigation.

Senior managers will be involved in future patient care investigations to ensure that they happen quickly and completely, he said.

Hospital officials say the problem was caused by a breakdown in patient care procedures.

The number of patients seen at the hospital’s Colby Campus emergency room the day the death occurred -171- “isn’t far off our average,” hospital spokeswoman Cheri Russum said.

Other problems listed by the state include having no record, either electronic or on paper, of how the patient was first treated after being brought to the emergency department, including notes on the initial check of his condition.

Improvements are being made to the hospital’s emergency department, traditionally one of the busiest in the state, Brooks said.

Fifteen new positions have been added to the 180-member emergency department staff over the past six months. Plans are now under way to add four patient treatment areas by summer, he said.

Reporter Sharon Salyer: 425-339-3486 or salyer@

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