HospitalInspections.org

Based on clinical record review and interviews with staff the hospital failed to ensure that the medical record for 1 of 11 (Patient #1) patients reviewed contained the appropriate information regarding allergies. The findings include:
a. Patient (P) #1 had been previously admitted to the hospital on 8/27/13 and the electronic medical record (EMR) Program A indicated P#1 had no known drug allergies (NKDA). According to the EMR on 9/3/13 an allergy to Vancomycin was added to P#1's profile.
b. On 9/13/13 the hospital underwent an EMR conversion from EMR Program A to EMR Program B. Interview with the Clinical Information Officer (CIO) on 12/11/13 at 3:30 PM identified that on the day of the EMR conversion, the facility was aware that the two systems did not transfer identified information including allergies. Therefore identified areas of all current (9/13/13) inpatient medical records were cross referenced from Program A to Program B and information was compared and updated, including allergies. Upon surveyor inquiry the CIO indicated this was the usual plan used by facilities when converting one EMR to another.
c. During admission to the hospital on 10/3/13 P#1 and his/her family indicated to the admitting nurse that P#1 did not have any known drug allergies. P#1 was admitted to the hospital with diagnoses that included gastrointestinal and ovarian cancer. Upon admission the EMR Program B failed to identify P#1's allergy to Vancomycin previously identified in EMR Program A.
d. Upon admission P#1 was diagnosed with septic shock and Vancomycin was started. P#1 received Vancomycin 1.25 grams intravenous once on 10/3/13 at 7:08 PM and a second dose of Vancomycin 1.5 grams was administered on 10/5/13 at 9:51 PM.
e. On 10/6/13 P#1 developed skin excoriation, shortness of breath, increased heart rate and he/she required administration of oxygen. P#1 was transferred to the medical intensive care unit (MICU). In the MICU the medical team reviewed P#1's prior electronic medical record (Program A) and noted the documentation of an allergy to Vancomycin. The Vancomycin was discontinued and P#1 was treated with alternate antibiotics. P#1's condition deteriorated and palliative care was initiated in consultation with his/her family and given P#1's poor prognosis. P#1 expired on 10/24/13.
f. Interview with the Chief Medical Officer (CMO) on 12/12/13 at 1:15 PM, the CMO indicated the cause of P#1's deterioration and subsequent demise was related to sepsis and the advanced ovarian cancer.