HospitalInspections.org

Based record review and interview the facility failed to ensure that the pharmacy had a mechanism in place to safeguard patients from receiving medications above manufacturer's recommendations for 1 (#1) of 10 patients reviewed.

Findings:

During medical record review for Patient #1 it was revealed that the patient arrived to the facility on 5/7/11 by Emergency Medical Services for altered mental status. The patient was transferred to 4 North at 10 PM. At 11:25 PM telephone orders were received for the patient. On 5/8/11 at 1:15 AM the patient received his medication that was ordered by the physician. On 5/8/11 at 3:15 PM the nurse received an order to change the patient's Abilify to 10 milligrams (mg). Review of the Medication Administration Record the patient received the following medication:

5/8/11 at 1:15 AM= Ability 30 mg and Zonegram 300 mg (3 capsules).
5/8/11 at 10:38 AM= Lopressor 25 mg, Os Cal 500 mg, and Theragran multivitamin
5/8/11 at 3:45 PM= Abilify 10 mg
5/8/11 at 7:43 PM= Elimite topical cream, Lopressor 25 mg, Os Cal 500 mg, Zonegram 300 mg (3 capsules), and Xanax 1 mg
5/8/11 at 11:47 PM= Xanax 1 mg

Interview with Patient #1 on 7/14/11 at 9:30 AM stated that while he was in the facility the nurse's overdosed him with his Abilify. He stated he has always taken Abilify 10 mg.

Interview of the Chief Pharmacist on 7/14/11 at 2:15 PM stated that when a patient is admitted the unit faxes the orders to the pharmacy. He stated that the medication order for Patient #1 was received at midnight on 5/7/11. The medication was dispensed to the unit and it would be expected that the nurse administer the medication to the patient at that time. He stated that in reviewing Patient #1's medical record it is noted that he had not taken his medication for days resulting in this hospitalization. He confirmed that according to the medication administration record the patient received a total of 40 mg of Abilify within a 24 hour period. He stated that in his opinion the dosage would not harm the patient. He confirmed that the computerized medication dispensing system does not have any safeguards to prevent a medication from being administered outside of the manufacturer's recommended dosage.

Review of the Nursing 2011 Drug Handbook revealed that the dosage for Abilify is 10 to 15 mg daily with a maximum dosage of 30 mg.