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PENN STATE HEALTH HOLY SPIRIT MEDICAL CENTER
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on a review of facility documents, staff interview (EMP) and medical record (MR) review it was determined the facility failed to ensure that the correct dose of medication was administered as ordered.
Findings include:
Review of the Medication Administration policy last reviewed 02/01/19 : "PURPOSE: The purpose of the Medication Administration policy is to ensure the patient will receive ordered medications in a safe and therapeutic manner. ... PERSONS AFFECTED: Hospital and Clinical Staff responsible for administering medications. ... POLICY: Geisinger will follow the following process for medication administration. ... C. Patient Safety ... 2. Verify the 5 rights of drug administration. ... d. Right dose: ensure that the dosage of the medication matches the prescribed dose and the prescription itself does not reflect an unsafe dosage level. ... ."
Review of MR 1 on February 5, 2020, revealed that patient received the wrong dose of Labetalol (used for high blood pressure) by intravenous (IV - medication administered directly into the blood stream) on December 23, 2019.
This was confirmed by EMP2 and EMP3.