Scripps Mercy Hospital

Report ID: O0N211.01, California Department of Public Health

Reported Entity: SCRIPPS MERCY HOSPITAL

Issue:

Based on interview and record review, the hospital failed to ensure that it's own policy related to the release of a placenta to the patient was implemented, for 1 of 2 sampled patients (1). Patient 1 was given the wrong placenta. Failure to follow policies related to the release of a placenta could lead to errors and the release of a potentially biohazardous (biological substances that pose a threat to the health of living organisms) tissue to the wrong person. This failure also had the potential to negatively impact a patient's emotional status, religion, ethnic or cultural beliefs.Findings: Patient 1 was admitted to the hospital on 6/29/13 for childbirth per the Facesheet. Patient 2 was admitted to the hospital on 6/29/13 for childbirth per the Facesheet.On 7/3/13 at 11:07 A.M., Patient 1 requested in writing the release of her placenta. At 11:40 A.M., a placenta was released to Patient 1.On 9/20/13 at 3:16 P.M., the hospital reported to the Department of Public Health that Patient 1 contacted the hospital on 9/13/13. Patient 1 informed them she removed the placenta from her freezer and identified that her name was not on the patient label that was located on the outside of the container that held the placenta. Patient 1 said that the patient label had Patient 2's name on it. A phone and joint record review with Registered Nurse (RN 1) was conducted on 5/14/15 at 1:05 P.M. RN 1 recalled that on 7/3/13, there was a placenta sitting on the nurse's station counter with documents. She stated that she ensured that all the documents were completed and released a placenta to Patient 1 per her request. RN 1 stated that she did not validate that the name on the patient label located on the outside of container holding the placenta was the same name as the patient receiving it. She explained that usually the patient's identification band was checked but in this case, any form of identification should have been checked prior to releasing the placenta to the patient. She acknowledged that she gave Patient 1 the wrong placenta. She also acknowledged that she did not follow the hospital's policy. According to the hospital's policy titled "Placenta, Release to Patient", dated 10/15/12, the policy's purpose was to establish requirements and a process for the release of the placenta to the patient. The policy stipulated to "Verify identification on the placenta container with the patient identification band."A phone interview with the Labor and Delivery Nurse Manager (LDNM) was conducted on 5/14/15 at 1:36 P.M. The LDNM stated that when releasing placentas per patient request, her expectation of the nursing staff was to check arm bands or identification. She acknowledged that the hospital's policy related to the release of a placenta had not been followed by RN 1 when she gave Patient 1 the wrong placenta. She acknowledged that RN 1 should have checked or verified the identification on the placenta container with the identification of the patient receiving the placenta.

Outcome:

Deficiency cited by the California Department of Public Health: Nursing Service Policies and Procedures.

Related Reports:

The report containing this deficiency also includes information about 2 other violations. Note that these may be related to the same event: O0N211.02, O0N211.03