HospitalInspections.org

Based on observation, interview and document review, the hospital failed to assure staff secured all medications in one of one obstetrical surgical suite.

Findings include:

- Observation of a cesarean section delivery of patient #57 on 11/3/10 revealed the completed cesarean section at 8:52am with the patient transferred for post-anesthesia care by the hospital staff including anesthesia staff K. All hospital staff exited the surgical suite. The anesthesia cart remained unlocked. At 9:05am, housekeeper G entered the surgical suite. Observation of the anesthesia cart revealed the unlocked anesthesia cart contained the following:

1.) Bipivocaine 30ml (milliliter) a local anesthetic- six vials;
2.) Epinephrine (an emergency medication) - 3 ampules;
3.) Lidocaine 1.5% solution (a local anesthetic medication) - one vial;
4.) Ultane (a general anesthetic medication)- one-half bottle;
5.) Suprane (an inhaled anesthetic medication) one-fourth bottle;
6.) Isoflovane (an inhaled anesthetic medication) - full bottle and;
7.) Two sealed anesthesia medication trays.

At 9:31am, the cart remained unsecured.

Chief of Anesthesia, physician I, interviewed on 11/3/10 at 12:45pm, stated the medication carts must be locked when licensed staff are not present.

Head of hospital pharmacy services, staff J, interviewed on 11/3/10 at 1:25pm, confirmed the medication carts are to be locked when licensed staff are not present.

The hospital policy titled "Medication Storage and Security" directed "Medications stored outside the pharmacy-operated storage area must remain secure at all times".

The hospital failed to prevent unauthorized access to medications in the unsecured anesthesia cart with the potential for drug theft.

Based on observation, staff interview and document review, the hospital failed to assure outdated, unusable drugs and biologicals were not available for patient use in one medication refrigerator located on the Cardio-Vascular Progressive Unit and one crash cart located on the Cardio-Thoracic Surgery Unit.

Findings include:

- Review of the policy and procedure on 11/3/10 titled, "Management of Expired Medications", directed staff, "BEYOND-USE-DATE...A medication is not to be used after it's beyond-use-date."

- Observation on 11/2/10 at 9:20am revealed a crash cart, number one on the Cardio-Vascular Progressive Unit, contained two 250cc, (centimeters) Intravenous (IV) bags of 5%Dextrose and Water which expired on 5/10 and 9/10, and one 1000cc bag of Lactated Ringers which expired on 10/10.

Staff A interviewed on 11/2/10 at 9:20am acknowledged the crash cart contained expired IV fluids.

- Observation on 11/3/10 at 8:30am revealed a medication refrigerator in the medication room on the Cardio-Thoracic Surgery Unit contained three 1000cc bottles of Normal Saline for irrigation with expiration dates of November, 2009 and October, of 2009.

Staff B and F interviewed on 11/3/10 at 8:30am acknowledged the irrigation fluids had expired.