HospitalInspections.org

Based on clinical record review, document review, and staff interview, it was determined the facility failed to ensure nursing followed hospital policy of having a second licensed staff member double-check medication being administered to a patient prior to a pharmacist review. This deficient practice was found in one (1) of ten (10) records reviewed, and resulted in an incorrect dose of medication being administered to a patient (Patient #3). Failure to complete safety checks of medications can result in continued medication errors with potential negative outcomes for all patients in the facility.

Findings include:

1. The policy entitled "After Hours Medication Review", issued and approved 7/31/13, was reviewed on 3/17/14. It states, in part, under the heading "Procedure....If a medication is obtained prior to pharmacist review, a second licensed individual authorized to administer medications will provide a double-check of the order and the medication."

2. The medical record for Patient #3 was reviewed on 3/17/14 and revealed an admission date and admission orders dated Saturday 1/18/14, with admission to the Adolescent Unit/Two (2) West. The admission orders included an order for "Hydroxyzine 25 (twenty-five) mg (milligrams) PO (by mouth) BID (twice daily at times scheduled by hospital policy)". The Medication Administration Record (MAR) was reviewed for the dates 1/18/14 through Monday 1/20/14 and revealed documentation of Hydroxyzine 25mg administered at 0900 and 2100 on 1/18/14 and 1/18/14, with a single set of staff initials indicating administration of the medication as completed.

3. The Pharmacy and Therapeutics Committee meeting minutes dated 2/21/14 were reviewed on 3/18/14 and revealed a report by the Pharmacist in Charge which stated, in part, under the heading "3. New Business, subpart g)medication errors dispensed/administered directly to the patient for January: One (1) on Two (2) West...error found per Pyxis report. New order for Hydroxyzine Pam 25mg and 50mg was overridden out for patient."

4. The auto-generated pharmacy report dated Sunday 1/19/14 was reviewed on 3/18/14. It revealed the entry "Hydroxyzine Pamoate 50mg
capsule" as removed from the Pyxis, labeled "override", dated 1/8/13 at 2033, with the Pyxis user, and Patient #3's room and bed number identified.

5. An interview was conducted with the Director of Quality Assurance (QA) on 3/18/14 at 1130. She stated that the Pharmacist in charge was the individual who first detected the medication error, documented it, and reported it to the physician. She stated that Pharmacy is "not in-house on the weekends" and reports from the Pyxis (the automated medication dispensing system used in the facility) are generated by Pharmacy daily "when they are here". When asked if a medication error using the Pyxis could go undetected from Friday afternoon until Monday morning when the pharmacist returned, she agreed that this could happen, and agreed that this had happened in this case. She stated that part of orientation for nurses hired at the facility includes review of policies and procedures. She stated that the staff person responsible for the medication error had received "re-education".

6. An interview was conducted with the DON on 3/18/14 at 1245, at which time the policy entitled "After Hours Medication Review" and Patient #3's MAR for the dates 1/18/14 through 1/31/14 were reviewed. When asked if there was any place in the Pyxis system or the paper medical record in which a second licensed person could document a double-check of the medication, she replied "No". She agreed that no documentation was present in the medical record to indicate this double-check had taken place on any of the three days the medication was administered to Patient #3 prior to review by the pharmacist, per hospital policy.

7. An interview was conducted with the Pharmacist in Charge on 3/19/14 at 1045. He stated Pharmacy is not in house for medication review during evening and weekend hours. He stated he reviewed the auto-generated pharmacy report dated Sunday 1/19/14 when he arrived for work the next morning, Monday, 1/20/14, and then discovered the medication error, notified the physician and documented the event. He reported that the Pyxis system is not currently set up to require or prompt a second set of initials by licensed personnel to document a second-check of a medication removed prior to pharmacist review.

8. An interview was conducted with Registered Nurse (RN) #1 on 3/18/14 at 1450. When asked to describe her procedure for administering medications prior to pharmacist review, she stated she would "override the Pyxis, type in the patient's name and room number, check the physician's order and administer the medication". When asked if she conducted any further safety checks prior to administering the medication, she reported "sometimes I go online to research the medication".

9. An interview was conducted with Registered Nurse #2 by telephone on 3/18/14 at 1510. When asked to describe her procedure for administering medications prior to pharmacist review, she stated she would "call the doctor to verify the order if it's something new, compare the orders to the medication reconciliation, override the Pyxis and give the medication". When asked if she conducted any further safety checks, she replied, "I verify allergies".

10. An interview was conducted with LPN #1 on 3/18/14 at 0700. When asked to describe her procedure for administering medications prior to pharmacist review, she stated she would "override the Pyxis", check the med. against the Pyxis and the order, check the patient's armband, date of birth, name and photograph, and administer the medication". When asked if she conducted any further safety checks prior to administering the medication, she replied "I check the allergies".

11. An interview was conducted with LPN #2 on 3/18/14 at 1300. When asked to describe her procedure for administering medications prior to pharmacist review, she described the process for using the override function in the Pyxis. When asked if she conducted any further safety checks prior to administering the medication, she replied that she verifies the medication in both the Pyxis and the MAR. She added that a second licensed person was required to "double check the narcotics".