Jun 04,2008 00:00
Cascade Healthcare Community Saddened By Accidental Patient Death At St. Charles Medical Center-Bend; Organization Reviews Tracheostomy Procedures
BEND, Ore. – On Saturday, May 31, a patient died at St. Charles Medical Center-Bend following a possible medical error, the hospital reported.
“We send our deepest condolences to the patient's family, and want to assure the community that this was an isolated incident," said James A. Diegel, FACHE, president and CEO of Cascade Healthcare Community. "We have already found areas of improvement and are implementing new procedures to mitigate this risk going forward."
The patient, a 64-year old man from Washington State, was admitted to St. Charles Bend on May 3. Due to injuries sustained in a motor vehicle accident the patient required a tracheostomy tube, a tube placed surgically through the neck to the trachea. CHC leaders believe this patient’s tracheostomy tube may have been incorrectly adjusted Saturday night by a caregiver, resulting in a compromised airway. As with any event that adversely impacts a patient, CHC leaders immediately investigated the incident.
After interviewing caregivers and reviewing the circumstances, CHC contacted the Bend Police Department and asked for assistance with the investigation. CHC and law enforcement together have determined that the incident was accidental.
In response to this incident, CHC has taken immediate steps to change work procedures related to this type of treatment. Additional safety measures have been put into place, and education for employees on the proper scope of duties is being conducted. CHC is also working at the state level to alert other health care institutions to the risks of possible errors when using the tracheostomy device, and has suggested new work procedures for all caregivers tending to patients with this type of device.
“It’s not enough to say we’re sorry,” Diegel said. “We are using this incident to educate our own staff, and also to help other health care providers across the region and the nation learn from this incident.”
Although the investigation is ongoing, CHC is sharing details of this incident to make sure the community understands what happened. CHC wants all caregivers, physicians and our community to know that immediate changes will be implemented throughout the organization to reduce the risk of this type of event going forward.
CHC is in the process of reporting the incident to all required regulatory agencies, as well as voluntarily reporting to other agencies with the hope of alerting health care providers across the region and the nation to a potential risk for error.