HospitalInspections.org

Based on document review and interviews, the hospital failed (for one of ten patients sampled) to ensure the appropriate use of the hospital's internal secure messaging system (TigerConnect) by a resident physician, resulting in an inadvertent medication error to Patient #1.

Findings include:

The hospital report, dated 09/24/2024, indicated that on 09/16/2024, a Post Graduate Year 1 (PGY-1) physician resident inadvertently ordered the medication Sotalol (a medication intended to affect heart rate and/or heart rhythm) for Patient #1 but the medication Sotalol was intended to be ordered for Patient #2. Patient #1 inadvertently received one dose of the Sotalol on 09/16/2024. Patient #1 remained at the hospital overnight for heart monitoring and Patient #1 was discharged the next day, on 09/17/2024.

The document titled Solutions Plan, last updated 12/02/2024, indicated that the root cause of the medication error to Patient #1 was the incorrect use (ambiguity regarding which patient was supposed to receive Sotalol) of TigerConnect. The Solutions Plan indicated that education regarding appropriate use of Tiger Connect would be disseminated to all physician residents and/or physician fellows.

The surveyor interviewed the Associate Chief Medical Officer (aCMO) for Quality on 12/16/2024 at 4:00 P.M. The aCMO for Quality confirmed that as of 12/16/2024 (the date that the survey commenced) no e-mail nor education had been disseminated to the residents/fellows physician base of the hospital despite the event occurring approximately three months prior, on 09/16/2024.