Poor root cause analysis
One shortcoming stands out above the others: how the hospital was performing its root cause analysis of the Kwiatkowski incident.
"The analysis did not contain the necessary scope to address all causal factors," the report says. "Although the analysis looked at infection control and medication security, it did so with a very narrow focus. Based on the findings, a much wider scope for both was necessary to establish a true root cause, providing the ability to analyze and evaluate the quality of their existing programs pertaining to infection control and medication security."
"During tour of the cardiac catheterization procedure room on 9/17/12 at 11:50 a.m.," the report continues, "medications were found in an unlocked refrigerator" and a member of the cath lab staff "confirmed that medications were not locked even during off hours." And the hospital had still, during the September federal inspection, not figured out how to secure medications in the cath lab, to which Kwiatkowski allegedly had unauthorized access before his termination.
You'd think after three tries, Exeter would get this thing right, so it might live past its dubious distinction as the home of the "serial infector."
As Martin warns, this is their last shot.