HospitalInspections.org

Based on policy review, record review, and staff interview, it has been determined that the hospital failed to administer intravenous medications in accordance with approved policies and procedures relative to the administration of propofol (a medication used for sedation) for 1 of 2 patients reviewed for medication administration, Patient ID #1.

Findings are as follows:

1. Review of the hospital's policy titled, "Medication Administration" last revised on 4/2022 states in part,
...Intravenous Medication Boluses

All intravenous (IV) medication boluses are to be administered through a pump from a dedicated bolus medication bag, and not directly from the primary medication infusion bag ..."

Record review for Patient ID #1 revealed she/he presented to the emergency department in May of 2022 in respiratory distress, unresponsive, and was not maintaining his/her airway. As a result of his/her presentation, it was decided that she/he be intubated.

Review of physician orders revealed that on 5/18/2022, propofol was ordered "STAT," indicating it was to be administered immediately. Further review revealed that this medication was to be administered as a continuous intravenous infusion at a rate of 2.67 milliliters per hour.

Additional review for this medication order revealed a section titled, "Components Summary" which indicated that the propofol was dispensed as a 50-milliliter vial.

Review of "ED [Emergency Department] Notes" by Employee A, Registered Nurse, dated 5/18/2022 at 2:32 PM, revealed that 500 mg of propofol were administered, the physician was notified and Levophed (a medication used to treat low blood pressure) was initiated.

Review of an "ED Course" note completed by the physician on 5/18/2022 at 3:47 PM states in part, " ...received a bolus of propofol unintentionally, required few minutes of pressors to maintain blood pressure and was stopped after recovery from propofol ..."

During a surveyor interview on 5/25/2022 at 12:35 PM and on 5/26/2022 at 8:55 AM with Employee A, he revealed that while assisting with Patient ID #1's care in the critical care area, the attending physician verbally ordered propofol to be administered for intubation. He indicated that he retrieved the propofol, programmed the infusion pump to the ordered settings, spiked the bottle that the propofol was dispensed in, primed the infusion line with the medication, and connected the infusion line to the patient. He revealed that he was trying to do things quickly to transport the patient to imaging and noticed that within a minute the infusion of propofol was completed. He revealed that the physician was notified immediately that a bolus dose of propofol was given, and the patient was then reattached to monitoring equipment at which point Levophed (a medication used to treat low blood pressure) was initiated. He indicated that he does not remember if he clamped the infusion line or if he attached the line to the infusion pump since he was trying to do things quickly.

During a surveyor interview on 5/26/2022 at 12:19 PM with the Clinical Education Coordinator, he indicated that when intravenous medications are to be administered, the expectation is that the nurse follows the infusion line connected to the medication bag from the bag to the infusion pump and then to the patient to ensure it is connected at the proper site.