HospitalInspections.org

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Based on document review, interview, and review of hospital policies and procedures, the hospital failed to ensure its pharmacy policies reflected current practice by the hospital's professional staff.
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Failure to update clinical policies and procedures puts patients and staff at risk of unsafe dispensing or mismanagement of controlled substances.
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Findings:
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1. The hospital's policy and procedure titled "Medication Narcotic and Controlled Substance Security and Documentation" (Policy # WR.333.43); (Approved 11/13/2015) under section "PURPOSE" read: "To ensure accurate and efficient accounting of controlled substances in order to prevent diversion."
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2. On 1/21/2016 at 4:30 PM, Surveyor #1 interviewed the hospital's pharmacy director (Staff Member #1) about departmental processes on controlled substances accounting. Staff Member #1 acknowledged that policy "Medication Narcotic and Controlled Substance Security and Documentation" was undergoing review and revision and the current posted policy did not reflect current practice in the department. These new practices included the implementation and review of a daily comparison report for receipt and deliveries of controlled substances; visitor access sign-in procedures to the pharmacy; and enhanced documentation of the "Pharmacy Technician Check" technician program. S/he stated the entire pharmacy staff received formal training and education on the new processes in early September but the hospital had not approved the final policy at the time of survey. At the time of the interview, Staff Member #1 presented a draft copy of the policy to the surveyor.
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Based on document review, interview, and review of hospital policies and procedures, the hospital failed to follow its policies involving discrepancies in controlled substances accounting.
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Failure to resolve discrepancies in controlled substances accountability risks medication errors and potential diversion for patients and staff.
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Findings:
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1. The hospital's policy and procedure titled "Medication Narcotic and Controlled Substance Security and Documentation" (Policy # WR.333.43); (Approved 11/13/2015) under section "4. Narcotic Count" read in part: "If there is a discrepancy in the count, all people directly involved will remain in the hospital until the discrepancy is resolved and/or the proper people have been notified and appropriate action taken. Any discrepancy that remains unresolved must be reported to the Pharmacy and an Electronic Incident Report (EIR) is completed."
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2. The hospital's policy and procedure titled "Controlled Substances - Storage, Documentation and Dispensing" (Policy #30.333.33); (Approved 6/5/2015) under section "2. Dispensing Discrepancy." read in part: "2.2 If Nursing is not able to resolve the discrepancy: 2.2.1. Pharmacy prints out activity report; 2.2.2. Looks for error; and 2.2.3. Contacts nursing unit to resolve discrepancy . . . 2.4 If the discrepancy is still not resolved, an Electronic Incident Report Form (EIR) is filled out. Steps that were taken to resolve the discrepancy are listed in the EIR."
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3. On 1/22/2016 at 7:30 AM, Surveyor #1 reviewed the January 22, 2016 hospital discrepancy report with pharmacy pyxis technician (Staff Member #2). Surveyor #1 observed there were eight unresolved discrepancies involving five clinical areas. Two of the clinical areas (Gastrointestinal (GI) lab and Surgical Floor) had discrepancies which exceeded 96 hours and included one discrepancy which was 15 days old. In an interview with Staff Member #2 at the time of the document review, s/he confirmed that they had contacted the clinical area leadership but had been unable to resolve the discrepancy. Staff Member #2 confirmed that s/he had not yet notified pharmacy management of the prolonged unresolved discrepancies.
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4. On 1/22/2016 at 11:25 AM, Surveyor #1 requested the incident reports for the GI lab and Surgical Floor for review. Hospital staff members were unable to provide evidence that there was an incident report on file for those clinical areas.
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5. On 1/22/2016 at 11:45 AM, Surveyor #1 inspected surgical floor medication room and confirmed with the nurse team leader (Staff Member #3) that SURB2 pyxis machine had a red icon denoting a discrepancy on the automated dispensing machine. S/he was unaware there were two unresolved controlled substance discrepancies.
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