HospitalInspections.org

Based on observation, interview, and causal analysis documentation, it was determined that the hospital failed to effectively track performance improvement actions to ensure they were fully implemented and sustained in all parts of the hospital that utilized similar processes and were at similar risk, as required.

Findings include:

1. Review of a document titled, "Pharmacy Process Improvement Project," dated 10/2011 reflected a causal analysis for an IV medication error. The "Identify Problem," section of the project reflected, "Nurse on inpatient care unit selected 'metronidazole' from the Pyxis [automated medication dispensing unit] profile for the patient. This IV piggyback (IVPB) was packaged in foil and housed in the tower component of the Pyxis. A piggyback for potassium chloride was also in a foil packaging and adjacent to the metronidazole. The nurse inadvertently gave the patient the potassium chloride instead of the intended metronidazole.

Review of the goal for the project reflected, "Prevent errors with drugs in look-alike packaging by making identification of the intended product easier and more clear."

Review of the "Determine Root Cause," section of the project reflected, "...A review of the stocking pattern in that Pyxis device showed that...Several different [IV] piggybacks came in foil-type packaging...There was sufficient room in the tower to rearrange the drugs and avoid having more than one on the same level...This could occur wherever a tower was used to stock IV piggybacks..." The solutions for preventing future errors included, "All units with a Pyxis tower containing IVPBs were reconfigured to avoid having an IVPB in foil-type packaging near another..."

Review of the results of the project included, "No additional errors of such scope have occurred...The initial plan for mitigating errors of this nature appears to have been successful..."

2. During a tour of the ICU with Nurse A on 07/03/2012 at 0930, the ED Pyxis tower was observed. The tower contained several shelved compartments. Each compartment housed multiple different medications.

The top compartment of the ICU Pyxis tower included two medications in foil-type packaging which were housed adjacent to each other on the same shelf. One of the medications was IV Levofloxacin. The other medication was IV Dobutamine. The third compartment of the Pyxis tower included two medications in foil-type packaging which were housed adjacent to each other on the same shelf. One of the medications was IV KCl. The other medication was IV Dopamine. These observations were conducted with Nurse A and Nurse F present.

During an interview with Nurse A on 07/03/2012 at 0940, he/she stated that each of the medications in the foil-like packages should have been separated in accordance with the solutions identified during the causal analysis dated 10/2011.

3. During a tour of the ED with Nurse A on 07/03/2012 at 0945, the ED Pyxis tower was observed. The third compartment of the Pyxis tower included five bags of IV Levaquin in foil-like packaging which were housed on the same shelf adjacent to six bags of IV Metronidazole in foil-like packaging. The fourth compartment of the Pyxis tower included seven bags of IV Levaquin in foil-like packaging which were housed on the same shelf adjacent to three bags of IV magnesium sulfate in foil-like packaging. These observations were conducted with Nurse A present.

4. During a tour of the CVU with Nurse A on 07/03/2012 at 1000, the CVU Pyxis tower was observed. The top compartment of the Pyxis tower included a bag of IV Dobutamine in foil-like packaging which was housed on the same shelf directly behind two foil-like packages of injectable Milrinone Lactate. These observations were conducted with Nurse A present.

5. During an interview with the Director of the Pharmacy Department on 07/03/2012 at 1010, he/she was informed that during observations of three Pyxis towers, it was identified that IV medications in foil-like packaging were stored adjacent to each other in the same compartment and on the same shelf. He/she stated that bags of medications in foil-like packaging should not be stored next to each other in the Pyxis towers. He/she acknowledged that the preventive actions from the causal analysis were not fully implemented in all areas of the hospital at similar risk as planned.