HospitalInspections.org

Based on hospital policy review, medical record review, incident report review and staff interview the hospital failed to communicate incident reports of two patients with nursing leadership to coordinate and prevent a recurrence of delays with critical lab draws in 2 of 2 records reviewed. (Patient #13, Patient #14)

Review on 09/28/2023 of the hospital policy Quality Assessment Report, revised 08/29/2023 revealed "...II. POLICY To promote quality patient care and identify and reduce incidents that could result in injury...a. An ongoing program monitoring patient care issues and the environment of care, b. An ongoing process to revise policies and procedures as necessary and appropriate to minimize patient, team member or visitor injury, c. An ongoing systematic effort to achieve those goals...V. PROCEDURE C. Manager ...2. if two departments are involved, it is the responsibility of the reporting department manager to coordinate with the other department manager to determine who will close the report. It is important for both department managers to review the incident and enter necessary comments prior to closing the report. 3. The Manager will be responsible for the following details about the event: a. Identification of any policies/procedures in place. Were policies followed? b. Identification of contributing factors. c. Identification of any actions taken or to be taken to prevent recurrence of a similar event..."

1. A closed medical record review on 09/28/2023 revealed Patient #13, a 39-year-old female admitted on 08/18/2023 at 0952 for Altered Mental Status, and Sepsis (infection in the blood) due to urinary tract infection, and fever. Review of the History and Physical 08/18/2023 at 1323 by Family Nurse Practitioner (FNP) #4 revealed a Vancomycin (broad spectrum antibiotic) was being given intravenously. A Vancomycin Trough level (to improve antibiotic penetration and optimize the likelihood of achieving pharmacokinetic targets 15-20 milligrams (mg) per liter) was reviewed in the record dated 08/19/2023 at 1321 that resulted as 23.4 (above the therapeutic range). Review revealed an additional Vancomycin Trough was ordered by MD #5 on 08/19/2023 at 1453 with priority "timed, order class: lab collect" for 08/20/2023 at 0800. Review of the record failed to reveal the lab was drawn from Patient #13 for 08/20/2023 at 0800. Review of the Ancillary Note 08/20/2023 at 1737 (8 hours later) by PharmD #6 revealed "...Assessment/Plan: ...Lab is behind and still has not collected the 08/20 0800 random vancomycin level that was ordered this morning; therefore, to not further delay care will use INsightRX data above to start a maintenance regiment of 1000 mg IV (intravenous) q (every) 24h (hours)..." On 08/21/2023 at 0223 the next Vancomycin Trough level resulted as 29.2 (displayed in red, and above therapeutic range). Medical record review revealed after the missed Vancomycin Trough level ordered for 08/20/2023 at 0800, Patient #13's labs were displayed in red and outside of therapeutic range. Patient #13 was discharged on 08/27/2023 at 1735 to home.

Internal Incident Report review on 09/28/2023 for Patient #6 dated 08/20/2023 and completed by PharmD #6 revealed a Vancomycin Trough blood draw was not completed as ordered on 08/20/2023 at 0800. PharmD #6 had completed and marked the ERL (employee reporting system) for a Laboratory Event, E. for harm, temporary intervention needed. Review revealed after hospital risk reviewed the incident, it was downgraded to follow up level- D. (required monitoring). Safety Behaviors: supporting each other, communicating with each other.

Interview on 09/28/2023 at 1311 with PharmD #6 revealed "...The MD will write the order for the Pharmacy to assist with dosing Vancomycin. When the lab draw was missed, I used my best judgement at that point in time reviewing the patient's lab work, and using a computerized program for dosing..." The interview revealed PharmD #6 marked the ERL- E. for harm, temporary, intervention needed when completing the incident report due to the missed vancomycin trough draw for Patient #13 because the lab result was needed to prepare and order the next vancomycin dose. The interview revealed a Physician Order for Vancomycin Trough was not followed for Patient #13. There was a best judgment made by PharmD #6 to prevent any further medication administration delays for Patient #13.

Interview on 09/28/2023 at 1320 with Pharmacy Manager revealed "...If the ERL was tagged as a laboratory event, I would be unaware the report had been filed..." The interview revealed the Pharmacy Manager was unaware that the incident report for Patient #13 had been filed because it was marked as a laboratory event.

Interview on 09/28/2023 at 1328 with the Laboratory Manager revealed "...This Patient was in ICU and would have been unit collect (Nurse from the Unit would draw the lab). Since the order was cancelled, and reordered for lab collect status I couldn't find the original order for review. We had minimum staffing on that day (08/20/2023), but we met the minimum requirements..." Interview revealed since the Vancomycin Trough order was cancelled and reordered for Patient #13 on 08/20/2023 the Lab Manager could no longer see if the Physician Order for Patient #13 was for lab collection or for unit collection. Interview revealed the incident report was not shared with nursing leadership in the ICU to problem solve and prevent future missed laboratory draws. The interview revealed hospital policy was not followed.

Interview on 09/28/2023 at 1540 with Nurse Manager of ICU, RN #8 revealed "...the ICU Nurse does all the labs in the department normally. If the Nurse tries twice without success, she calls the lab to collect the blood drawn from the patient..." The interview revealed RN #8 was not informed of the delay in Vancomycin Trough on 08/20/2023 at 0800 for Patient #13 or reviewed the ERL. Interview revealed hospital policy was not followed.

Interview on 09/28/2023 at 1545 with Chief Nursing Officer, RN #7 revealed "...there's was an opportunity for the Laboratory Manager (named) to communicate with Nursing Leadership. There should have been a phone call, and nursing should have been added as a department on the ERL. There should have been nursing partnership to fully follow up..." Interview revealed the Lab Manager and Nursing Department should have collaborated on any delays with lab collection/blood draws to prevent further incidences. The interview revealed hospital policy was not followed.

2. A closed medical record review on 09/28/2023 revealed Patient #14, a 94-year-old female admitted from home after a fall and diagnosed with a Non-ST Elevation Myocardial Infarction (coronary artery blockage). On 08/18/2023 at 2146 Medical Doctor (MD) #3 a ordered a Heparin (reduces blood clotting) Infusion to be started, with initial dose specific to Patient #14's weight starting at 12 units/kilogram/hour (6.9 milliliters/hour) [ml/hr.]. Lab work was to follow every 6 hours to titrate the Heparin dose to ensure therapeutic range was obtained. On 08/19/2023 at 0434 an Anti-Xa [measures plasma heparin in the blood with therapeutic range 0.3 - 0.7 IU/ml [international unit/milliliters] was drawn and resulted as 0.40 (within therapeutic range). On 08/19/2023 at 0554 an additional Anti-Xa lab draw was ordered for 1107 by MD #1 "Order Class: Lab collect." Review of the record failed to reveal the lab was drawn from Patient #14 on 08/19/2023 at 1107. On 08/19/2023 at 1459 a new order was placed by Registered Nurse #2 for Anti-Xa to be drawn at 1500 "order class: lab collect" for Patient #14. The lab resulted at 1544 as 0.35 UI/ml (within therapeutic range). Record review revealed a lab work order for Anti-Xa on 08/19/2023 at 1107 by MD #1 was not drawn for Patient #14. Patient #14 was discharged to a skilled nursing facility on 08/23/2023 at 1628.

Internal Incident Report reviewed on 09/28/2023 for Patient #14 revealed it was submitted anonymously on 08/19/2023. The ERL was marked as a Laboratory event. Review revealed the RN had attempted 2 times to collect the blood from Patient #14 for Anti-Xa scheduled for 08/19/2023 at 1107, and a phlebotomist was not found to assist, resulting in a delay in care. Review revealed the Anti-Xa was reordered and finally collected at 08/19/2023 at 1500. Review revealed after hospital risk reviewed the incident, the ERL was marked follow up level A. (no harm).

Interview on 09/28/2023 at 1328 with the Laboratory Manager revealed "...since the order showed unit collect and was cancelled and reordered not sure when this was flipped to lab collect...we were down to one phlebotomist in the hospital and one in the emergency department that day. It is generally announced in the safety huddle daily at 0830 when there are staffing issues. The lab techs (technicians) let the floor staff know...I don't have the ability to monitor a data trail...we are not getting a call every time, and this has been discussed..." Interview revealed when an order in (named medical record system) was changed to lab collect a phone call was made to notify the laboratory in addition to changing the order collect status on the order by nurse or provider. The interview revealed the incident report for Patient #14 was not forwarded to the nursing leadership for review. The interview revealed hospital policy was not followed for Patient #14.

Interview on 09/28/2023 at 1600 with the Nurse Manager of the Intermediate Unit (IMU), RN #9 revealed that she was unaware of the Incident report for Patient #14 previously, and it was not shared by the Laboratory. "...There was one phlebotomist that day, the RN asked for help, and had called the House Supervisor twice when the lab tech did not respond. The lab was not drawn in time, another order was placed and at 1544 resulted within therapeutic range for the Heparin infusion... This was a 'near miss' incident with no harm to the patient..." The interview failed to reveal an explanation for lab not responding to the RN or House Supervisor requests for assistance on 08/19/2023. The interview revealed the incident report was not initially shared with RN #9 for review. The interview revealed hospital policy was not followed for Patient #14.

Interview on 09/28/2023 at 1540 with Chief Nursing Officer, RN #7 revealed "...there's was an opportunity for the Laboratory Manager (named) to communicate with Nursing Leadership. There should have been a phone call, and nursing should have been added as a department on the ERL. There should have been nursing partnership to fully follow up..." Interview revealed the Lab Manager and Nursing Department should have collaborated on any delays with lab collection/blood draws to prevent further incidences. The interview revealed hospital policy was not followed.

NC00187474 NC00187470 NC00187514 NC00186875