FirstHealth of the Carolinas officials should know by the end of the month whether they have taken adequate corrective steps to prevent operating room fires like the one recently that burned the neck and shoulders of a patient during an emergency surgery at Moore Regional Hospital.

The N.C. Division of Health Service Regulation placed Moore Regional on “immediate jeopardy” status following an unannounced survey on Aug. 1, in response to the incident that occurred in late June.

FirstHealth’s corrective action plan is due Monday, after which follow-up surveys will be conducted by the state and the Centers for Medicare and Medicaid Services (CMS).

“We are working diligently to adopt and implement the recommendations noted in the survey,” David J. Kilarski, CEO of FirstHealth, said Friday. “We are committed to putting all the necessary policies and procedures in place to ensure every patient’s safety and provide the highest level of care.”

Kilarski called the fire “unfortunate.”

“We took immediate corrective steps that same day,” he said. “Our highest priority is for the safety of our patients and staff.”

FirstHealth, which operates Moore Regional and hospitals in Rockingham and Troy, revised its operating room fire safety policy “to prevent a surgical fire and to prevent injury to the patient in surgery,” according to records obtained by The Pilot.

“We’ve learned an awful lot from this, and hopefully it will never happen again,” said Dr. John F. Krahnert, chief medical officer for FirstHealth. “We are in a continuous quality and safety improvement environment.”

The initial survey followed two anonymous complaints: that a fire occurred in an operating room at Moore Regional, and that the hospital failed to notify the patient’s family.

“The complaint about the fire was substantiated,” Kilarski said. “The other complaint was unsubstantiated because we did notify the family.”

CMS defines immediate jeopardy as “a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident.”

According to the findings of the state survey, the Moore Regional operating room staff failed to ensure a patient’s health and safety. The hospital was cited for not following established fire safety prevention policies and procedures.

The fire that occurred has prompted CMS to review FirstHealth's operating room policies and procedures. That agency, which oversees hospitals’ ability to receive Medicare and Medicaid payment, conducts such reviews as a normal process to ensure hospitals develop and implement corrective policies.

During the emergency life-saving procedure in June, vapor from sterilizing fluid ignited, causing a brief flash fire that was immediately extinguished “with some sterile saline and wet towels,” Kilarski said.

The patient sustained small first- and second-degree burns to the neck and shoulders but no lasting injuries.

“The patient was discharged from the hospital and did not sustain any permanent injuries,” Krahnert said. “After a thorough investigation, we have determined that the operating room staff responded to the incident appropriately and then successfully continued with the original emergency procedure.

“Clearly, we preserved life in this case.”

The hospital was placed on immediate jeopardy status after the survey results were forwarded to the CMS office in Atlanta. Now both Moore Regional and its Richmond Memorial Hospital campus in Rockingham are subject to a full CMS survey, which FirstHealth’s administration expects will take place within a few weeks.

“These agencies are doing their job,” Kilarski said. "There was room for improvement for us. We’ve learned some things and can do a better job.”

With the immediate jeopardy status, both Moore Regional and Richmond Memorial risk losing their certification for Medicare and Medicaid reimbursement.

“It’s not going to happen,” Kilarski said. “I think we’ve got a wonderful plan that I think will satisfy them. If they want us to modify the plan, we’ll modify the plan. We’re confident that CMS will see the value of our plan.”

According to the records obtained by The Pilot, Moore Regional has already instituted several new policies to safeguard against a similar incident.

For example, alcohol-based skin preparation is now prohibited in any emergency surgery which does not allow sufficient drying time according to manufacturer’s instruction, usually three minutes or more.

Krahnert said FirstHealth has eliminated the use of alcohol-based preps “in an emergency situation where you have less than three minutes to save a life.”

“We’re going back to the non-alcohol-based preps such as Betadine,” he said.

ECRI Institute estimates 550 to 650 surgical fire accidents occur annually in the United States. Of those, only 20 to 30 are considered serious, which is defined as causing disfiguring or disabling patient injuries. One or two of the total fires are fatal, according to the ECRI website.

ECRI Institute is an independent, nonprofit organization based in Plymouth Meeting, Pa., that researches the best approaches to improving the safety, quality and cost-effectiveness of patient care.

(29) comments

Peter Mulcahy

Thank you, The Pilot, for keeping this thread alive. Too often stories and comments about MRHosp. are cut short or not reported. It's important and the unreported stories are out there.

"maybe time was not on their side in this case and they just had to proceed"

so therefore, it is not an absolute that "someone did not do their job", to reach the conclusion that "someone did not do their job" would require a knowledge of the events and circumstances more in depth than that which has been covered here. I fully trust that the proper steps have been taken to make sure it doesn't happen again. I didn't mean to infer that you were "attacking", I just happen to disagree with that particular point of your comment

Mark Hayes

I guess I could have worded what I was trying to get across, as one has commented on earlier that the fault being from MRH expanding, from the salary of their CEO's, and the use of cheap sub contractors, an opinion and rush to judgement unfairly placed upon the entire hospital and staff, all were in no way responsible as it was a human error, something that is an everyday possibility whichever hospital or medical facility. Reading back I guess I could have clarified that comment and deserve to be called on it.

"again SOMEONE did not do their job"

Unless I overlooked it, I see nothing in the article that bears this out. I fully believe FH staff and management of the OR left no stone unturned in their efforts to ensure this never happens again. Wouldn't you if you had a fire in your workplace? Everyone there was in danger for a brief period.

Mark Hayes

" SOMEONE did not do their job" or how else would this have happened, I am not in any way attacking MRH I just know that this would not have been such a widely covered event had certain guidelines had been followed. Bottom line and admitted by Dr. Krahnert the solution must not have sufficiently dried and did in fact ignite, after certain guidelines were not followed after the event which should have been. Most of all this comes from the article and interview with Dr. Krahnert, not me. Seems that the solution not being allowed to dry is where this all started, and yes that is the responsibility of whoever administers it, they also are supposed to notify the surgeons or make sure it is in fact dry before they proceed, or that is procedure in other hospitals when it is used, maybe time was not on their side in this case and they just had to proceed, who knows. The patient lived, many here have had their pound of flesh and life goes on. Still one of the best hospitals in the state, Duke, UNC and Cape Fear have all had their share of mishaps, forgive and forget or just do not go there, pretty simple. Their doing my knee and if need be I will wear a fire retardant smock.

Mark Hayes

Judging from the comments this story is really at a standstill, a lot of theoretical and not enough realistically, yes in theory things like this incident should not happen, but they really do, and it occurs everyday in many, many medical facilities across the globe. MRH has one of the highest ratings in this state for furnishing excellent care to those in need. With the operating room mishap drawing more attention than the saving of hundred of lives by this same facility each year it again shows the unappreciative nature of some who feed off having a target to place their revengeful nature.

John Nagy Staff
John Nagy

Carthagerez, due to federal patient confidentiality laws, the hospital could not disclose any identifying information about the patient. However, The Pilot is continuing to follow up on this story.

Patty Hibble

As a former employee of the MRH system, I can honestly say after 40 years working in the medical field at many hospital systems nationwide, MRH is one of the best! MRH continually looks for ways to improve processes with total involvement of staff members working directly with patients. The integrity of MRH is sound! If anyone has been a patient at other facilities, it is evident that staff at MRH truly strives to provide the best patient care possible. I don't think there is any other hospital system that could have provided better care to my husband when he needed cardiac services. There will never be a perfect hospital system anywhere because humans work in them. Before making negative remarks about MRH, investigate the improvements over the past 10 years and what benefits patients can have closer to home.

Angie Price

"No, I am not suggesting a conspiracy."

No conspiracy theories, just a request for in depth and investigative reporting

Mark Hayes

A conspiracy would mean an intentional cover up, what happened was just a person not doing their job, someone other than just the doctors are in charge of the operating room and reports are made on what goes on in those operating rooms, again SOMEONE did not do their job, that does not warrant such a avalanche of negative comments. Why so eager to degrade MRH when in fact it is a very highly rated facility, a hospital that had a operating room malfunction, could have, should have, but didn't, something we all are guilty of.

Angie Price

The information for this story seems to have come only from the hospital. No, I am not suggesting a conspiracy. However, it would be good to see a statement indicating that The Pilot attempted to speak with the patient or family to at least request comment. Would also be good to see evidence that the paper at least questioned some of the assertions or asked for more detail.

It is fortunate that the event was not more serious. Still, there are questions:
What constitutes "small" burns?
Was the patient's stay at the hospital extended due to the burns?
Did he or she suffer significant pain as a result of the injuries?
What is the likelihood of permanent scarring?

John Nagy Staff
John Nagy

Skippy, this story originally ran Friday on the Pilot's website and on the front page of The Pilot Sunday morning. Just fyi.

Peter Mulcahy

Mr. Nagy, I know exactly when the story first appeared. My point in my post about it making the front page of the Fayetteville Observer was that more than one newspaper was now exploring the story. Hence my comment about "sunshine" shining on ithe subject.

Peter Mulcahy

The wagons have circled and that's fine if you've never had a bad experience at Moore Regional. But people have had bad experiences and it's only a matter of time that the hype gives way to realistic discussions of improvement. The Fayetteville Observer ran this story on the front page this morning. Sunshine always helps a situation.

Comment deleted.
Mark Hayes

That makes absolutely no sense," sub par contractors", where do some of you come up with these comments, just throw it up and see what sticks, a human error, a mistake, an unfortunate and one of many that are made in hospitals other than MRH. Blood in the water and drawing sharks is what this has turned into. I wonder how many lives were saved today, yesterday and even the day of the accident but no one comments on those live saving measures that were taken.

Jordan Wright

Upon reading this account of what exactly occurred in the operating room accident, I cannot help but feel an overwhelming measure of anticipation for the development of this story. Although I can see that certain aspects of this incident have been omitted from the article above, I know that my relatives and I will do our part to make sure that no significant details are overlooked whenever this matter is resolved.

Mark Hayes

Keep us posted as I would like to get to the bottom of this mishap from someone that was involved and your comment has led me to believe that you were in the operating room or close by, you may be more knowledgeable than some others. As it appears to be the intent of some to tear away at the reputation of a great facility due to the mishap that COULD HAVE happened at any other facility.

Mark Hayes

To debate the quality of care at MRH is senseless, great hospital, great staff and if there are those who feel differently then Wake Med in Cary, or CCH in Sanford are right up the road. Being one who likes to see some validity in ones comments I would question the comment involving a cover up by MRH, that again is either an opinion, or in deed a fact, if so proof of the statement should be made known, if an opinion than that also should have been inserted into the comment, if not true let's just call it slander.

Peter Mulcahy

The reality of hospital care in the United States is dismal despite some of the preceding kudos from readers who don't seem to want to know the facts.
Studies over the past decade generally verify the following about our hospital system:

• 12,000 deaths per year due to unnecessary surgery

• 7000 deaths per year due to medication errors in hospitals

• 20,000 deaths per year due to other errors in hospitals

• 80,000 deaths per year due to infections in hospitals

• 106,000 deaths per year due to negative effects of drugs

This makes healthcare related accidents the third leading cause of death in the US after heart disease and cancer. And none of those people are dying and getting hurt at our hospital? I don't think so. Anytime federal overseers or regulators want to check out the hospital I use to insure quality healthcare outcomes for the patients, be my guest.

Andrew Auman

So, Mark, you are not glad to have the hospital in this county? Remember that when you need it. Maybe you'll be able to go to First Health in Hoke, which is about a mile from the new Cape Fear Hospital in Hoke. It's only about 30 miles from here. I, personally prefer First Health to spend our money improving MRH for the population that funds it. This "non-profit" is all about gobbling up every available medical facility in the area, in effect developing a monopoly on all health care. They have even started an insurance pool for the area that they serve. It is not the doctors who have made these decisions, only the administration.

Mark Hayes

My attempt to convey that we ARE fortunate to have MRH was brought on by your claims of a cover up. You seem to have far more knowledge than myself in that regard, I do know there was an accidental mishap but thankfully no one was seriously injured, as for the CEO and others being over paid there again you have access to information I am not aware of, I do know what a member of my own family makes, and also several of our friends, I also know the cost of the education that resulted in their achieving that pay scale and the years involved, as for the growth they are in competition as any business is to serve as many as possible which ultimately has a trickle down effect in cost to all of us. You may want to research Wake Med, and CCH, UNC and others, they all are constantly trying to expand their areas of service and care, what is wrong with that after all it is a business and if you do not grow you will die on the vine.[smile]

David craft

This may be the result of terminating so many with years of experience at the hospital. Surely, they had to expect consequences replacing so many dedicated people with newer staff...

" Now both Moore Regional and its Richmond Memorial Hospital campus in Rockingham are subject to a full CMS survey, which FirstHealth’s administration expects will take place within a few weeks."

This sounds like another government over reach to me. The situation was in the OR so why not focus any investigation to the OR? Instead the entire patient care staff is kept on edge while the government hunts for any proverbial needle in a haystack to justify their existence. The nurses bust their humps for 12 hours and thanks to this witchhunt they cannot even have a cup of water at their desk for a quick drink when they stop to chart. What does that have to do with a fire in the OR?

Andrew Auman

Certainly we are grateful to have MRH. The issue here is that First Health tried to cover up what was one of the most serious incidents one could imagine in an operating room. They had an objective withholding the information....a fine and potential "loss of status".They also withheld this information from the public, who donates millions of dollars to the foundation. Bad publicity. I, for one, would prefer openness and honesty rather than hearing months later that the incident was minor. How much, by the way, has First Health paid out to the unfortunate individual who was burned in this minor incident. First Health is too busy overpaying the CEO and numerous vice presidents, buying smaller medical facilities, and building another hospital in Hoke (not essential), and not enough taking care of their basic responsibilities. Why not spend money to improve that terrible service that you call an emergency room. Get back to serving the public that makes your existence possible!

Mark Hayes

" Certainly we are grateful to have MRH ", My fault for reading on past that sentence but, we all make mistakes, mine was reading that comment and yours was making it.

Deborah Sawyer

If there was a cover-up why was CMS notified immediately according to their regulations? Admitting the mistake was the right thing to do, any ethical facility or person would do that. Your conjecture and wild suppositions do nothing to advance truth and honesty. Tell us what you can prove, and I repeat prove. The most important point to remember is that FirstHealth is working to improve their process to make the OR a safer patient environment.

L Mckinney

CMS was notified by an anonymous tip, not by the institution.

William Craig

I understand the family is upset but feel sure First Health did all the right things to preserve life and safety.

We need to be grateful to have such a quality facility to serve us even with the rocks in the road that advanced medicine presents

L Mckinney

We should indeed be grateful for the benefits provided by FHC, however, that does not excuse issues of accountability. Which is the real issue in this case.

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