HospitalInspections.org

Based on observation, staff interviews, review of hospital policies and medical record reviews, the Pharmacy Service failed to provide oversight of medication orders received, failed to review the ordered medication for therapeutic duplication and monitor for potential medication errors and thus prevent a medication error in 1 of 3 sampled records (#23).
Findings Include:
Observation 04/22/2015 at 1015 on 2 Hall (Medical, Oncology and Pediatrics) during medication administration revealed pharmacy software on a medication administration cart screen that presented patient medication information in the following format:
1. Partial view of patient medications, and Patient #23 specifically
2. Listed medications in alphabetical order
3. Identical medications, each with differing names, including generics, are not identified.
The medication cart screen (TOP) showed the active order "Depakote (seizure medication) 500 mg (milligrams) tab PO BID (oral twice a day) (1000 and 2200) Generic: Divalproex ER". The screen (BOTTOM) showed another active order received on 04/21/2015 at 1135 "Valproic Sodium Soln (solution) (seizure medication) 250 mg/5ml (milligrams per milliliter) 5ml Ud (unit dose) 500mg PO QAM (every morning) 1000 and 1500 mg QHS (every evening) Generic Valproate Sodium".
The medication nurse was observed and heard to note that these two medications were the same and that she would call the physician to clarify the orders and hold both until she heard from the physician. She placed a call at 1020 to MD #1 who discontinued the Depakote and clarified to give only the Valproic Sodium Solution as ordered. This verbal order was written on the MD order sheet and signed by the RN (registered nurse) receiving it on 04/22/2015 at 1040. Review of the electronic Medication Administration Record (eMAR) revealed that on 04/21/2015 at 2200, the Depakote 500 mg PO Tab and the Valproic Sodium Soln (250mg/5ml) 1500 mg were administered. MD #1 was called again immediately and the RN assessed the patient for signs of overdose. MD #1 came immediately to assess Patient #23. No problems were identified by either assessment. No harm or further treatment was required. Unit Manager initiated a Medication Error Report describing the incident along with corrective actions, emailed the event to Pharmacy and assured the verbal medication clarification order was signed by MD #1.
Review of Pharmacy Policy Verification of Orders, states that Pharmacy is responsible for "#4 Duplication of therapy" in medication orders. Interview with the Director of Pharmacy revealed that the pharmacist working at the facility at that time missed the alerts for "duplicates of order entry" on 04/20/2015 and 04/21/2015 that appeared only on the pharmacy department's screens. The review of the alerts and conflicts also showed: Pharmacist Reviewed- No Action Required" responses for all alerts and conflicts.