HospitalInspections.org

Based on record review and interview, the hospital failed to ensure patients' right to receive care in a safe setting for one of one patient (Patient #1) who received a medication that was not ordered for her. The patient experienced discomfort after the incident.

Findings included:

Patient # 1's Physician Orders dated 12/19/14 at 22:45 noted the patient was hospital admitted with a chief complaint of suicidal ideation with the plan to cut her wrists. The patient was anxious and depressed. The orders included Milk of Magnesia for constipation, Mylanta for gastro-intestinal distress, Tylenol for pain, and Phenergan for nausea and vomiting as needed.

Patient #1's Physician History and Physical Examination dated 12/20/14 noted the patient was 20 weeks pregnant.


Shift Nursing assessment dated 12/20/14 at 23:00 noted Patient #1 reported anxiety because she had received a dose of Zoloft, an antidepressant medication. Patient #1 reported a headache and received Tylenol on 12/20/14 at 21:00, on 12/21/14 at 10:10, and on 12/21/14 at 23:10.

Hospital Personnel #5 acknowledged on 03/27/15 at 17:10 that Patient #1 received the dose of Zoloft.

Manufacturer's Most Common Adverse Reactions documentation noted headache and nausea as side effects of discontinuing Zoloft(www.zoloft.com).

The National Library of Medicine noted that "Animal studies have shown an adverse effect and there are no adequate studies in pregnant women..." (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0045066/#DDIC601237.side_effects_section).