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Based on review of documentation and interviews, the Hospital failed to ensure that performance improvement activities tracked medical errors and adverse patient events, analyzed their causes, implemented preventative actions and mechanisms that included feedback and learning throughout the hospital. Findings included:

Background information:

The Hospital reported on 6/22/10 a medication error in which the Patient's Hemodialysis catheter was incorrectly used for intravenous access. The Patient's diagnoses included end stage renal disease, terminal carcinoma of the esophagus and HIV. The Patient received dialysis. The Patient was transferred from an outside hospital for a laryngeal biopsy. Following the surgical biopsy, the Patient was admitted to the hospital for continued moderate bleeding from the mouth and coughing up blood clots.

1) Review of the Nursing Notes dated 6/9/10 indicated that at 2:45 PM, the Oncology Clinical Nurse Specialist flushed the Patient's Hemodialysis catheter which contained an indwelling solution of Heparin. The Heparin flush solution contained 2.1 ml of Heparin [5,000 units/ml] instilled in the blue lumen. The catheter was a double lumen catheter in the right chest wall that was not labeled. Hemodialysis catheters at the Hospital are routinely designated with a blue label and the warning "Hemodialysis Access - Do Not Violate." This Patient was transferred from another Hospital and the Hemodialysis catheter was not labeled. Following the medication error, the Patient continued with coughing up bright red blood and clots. The Patient was transferred to the Intensive Care Unit where oral packing of the oropharynx and hypopharynx was done under sedation and mechanical ventilation to stop bleeding. One unit of packed red blood cells, Protamine [a medication to reverse the effects of Heparin], fresh frozen plasma were administered to treat the decreased hematocrit. The oral packing remained in place for 32 hours. The Patient was in the Intensive Care Unit for approximately 2 days. Following discharge, the Patient was transferred to a Rehabilitation Center where it was reported the Patient left Against Medical Advice. The Patient went home to receive Hospice Care.

2) This particular medication error was identified as systemic because of the potential for this error to occur in other clinical units based on the large number of transfers to the hospital and admissions from other hospitals.

3) As of the date of the survey, 6/23/10, the Hospital had not identified and implemented adequate corrective actions to prevent this error from occurring hospital wide in its plan of correction.