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Based on interview and documentation review the Hospital failed to ensure that: 1). the physician who ordered the medication to which the Patient had an adverse reaction was aware of the outcome or was interviewed regarding the case, and 2). communication between nursing and pharmacy was addressed when the pharmacist identified an inappropriate medication order.

Findings included:

1).#### It was reported that on 6/4/10 the Patient developed abdominal pain. The nurse assigned to the Patient contacted the physician (on duty Hospitalist) for and order for pain medication. The physician entered an order into the Hospital's automated physician order entry system for Dilaudid 2-4 milligrams via intravenous every 3 hours as needed for pain (an opioid analgesic). The nurse acknowledged the order and used the override feature of the automated medication dispensing system to remove and administer the medication. Shortly after the medication was administered the Patient was found with agonal ( ) respirations and hypotension. A Code Blue was called, Narcan (a narcotic antagonist used to reverse the effects of narcotic overdose) was administered, the Patient was intubated (tube inserted into the mouth, down the throat and to the trachea to provide an airway), and the Patient was transferred to the Intensive Care Unit on mechanical ventilation. On 6/5/10 the Patient was successfully extubated and transferred back to the Telemetry Unit.

Review of the Hospital's medication ordering system determined that medication orders were either entered into the electronic system via a computer or, if handwritten, were scanned into the system. The orders were received by Pharmacy who was responsible for processing the order. The assigned Pharmacist had to review the order to determine if it was appropriate based on the patient medical record information. If the order was appropriate then it was entered into the electronic medication administration record as approved. Once approved it could be accessed by nursing staff for administration through the automated medication dispensing system. If the medication was not approved then the Pharmacist was responsible for contacting the ordering physician for clarification. Because most medications were restricted they could not be accessed by the nurse until the Pharmacist processed and accepted the order. However, the Hospital had developed a list, called an override list, of medications that could potentially be needed in an emergency and potentially could not wait for Pharmacy processing. The override feature allowed the nursing staff to access those medications on the list prior to pharmacy review. Dilaudid was one of the medications on the override list.

Review of the Hospital's investigation determined that the following concerns were included: the physician did not see the Patient prior to ordering the medication; the medication dose was an exceptionally large dose of medication, and the physician answered yes to the prompt - is the patient opiate tolerant (on opiate(s) for greater than 1 week) when record review revealed the Patient had not received an opiate prior to the order.

Review of the Hospital corrective action plan determined the following: counseling the nurse who administered the medication (done); nursing education (in process); referring the case to the Director of the Hospitalist group for review (done); referring the case to medical peer review (scheduled for 8/26/10); revision of the Parenteral Medication Administration Guideline for Dilaudid (done); distribution of the revised Guideline to all medical staff, and removal of Dilaudid from the override list (done).

The Hospitalist who ordered the medication was interviewed on 6/25/10 at 9:35 A.M. The Hospitalist reported that the interview was the first time the Hospitalist had heard of the Patient's adverse reaction to the medication.

Review of the corrective action plan determined that the Hospital had not identified and/or addressed the possible need for nursing/pharmacy communication when a medication that was on the override list was inappropriately ordered and if administered could be a danger to the patient.

Based on observation the Hospital failed to ensure that the physical plant in the ante-room of the Pharmacy was maintained in a safe and clean manner.

Findings included:

A tour of the Pharmacy was conducted on 6/25/10 with the Director of Pharmacy and the Vice President of Inpatient Services present.

The tour revealed that the Pharmacy overall was clean and in good repair with the exception of the area identified as the ante-room. The room preceded the room used for admixing and contained pharmacy supplies. Observation determined the floor was covered with commercial grade carpeting that was dirty, had multiple stains, and had a musty odor. The carpeting had duct tape over several areas holding seams closed. There was a slope in the floor near the exit of the ante-room to the admixing area that was not identifiable under the carpeting.