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Based on findings from medical record (MR) review and interview, in 1 of 7 MRs reviewed involving patients receiving antibiotics (Patient B), the patient received a dose of antibiotics 2 1/2 hours after the due time. The pharmacy did not ensure timely delivery of the antibiotic when the mode of administration was changed from intravenous (IV) to oral (PO).

Findings include:

--Review of Patient B's MR at 10:15 am on 9/23/14 revealed the following pertinent information:

Patient B was hospitalized for a submandibular abscess that required an incision and drainage procedure in the operating room on hospital day #4. This was his second hospitalization related to this infectious process. Postoperatively, intravenous (IV) antibiotics were ordered for administration every 8 hours (0900, 1700 and 0100 per hospital policy). On hospital day #5, at 0829 an order was entered in the MR, changing the antibiotic administration mode from IV to PO, still every 8 hours. As of 10:30 am on hospital day #5, per the Medication Administration Record (MAR), Patient B had still not received his next antibiotic dose due at 0900 that morning.

--Per interview of Registered Nurse #1 at 11:00 am on 9/23/14, he/she was awaiting delivery of the medication to the floor. The pharmacist who works on the floor was aware of the change in the order from IV to PO.

--Per follow up review of the MAR in Patient B's MR, the oral dose of antibiotics due at 0900 on hospital day #5 was not administered until 1153, 10 1/2 hours since the last dose of antibiotics administered (0122), nearly 3 hours past routine administration time (0900).