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Based on documentation review the Hospital failed to ensure that all corrective actions that had been developed in response to a medication error on the Neonatal Intensive Care Unit (NICU) had been implemented at the time of the survey.

Findings included:

The report, submitted to the Department of Public Health, indicated the following:

Infant #1, born at 25 weeks and 5 days gestation and weighing 650 grams, was admitted to the NICU with severe respiratory distress and hemodynamic instability. Surgery was performed to close a patent ductus arteriosus (a congenital heart defect which allows blood flow to go from systemic circulation to pulmonary circulation. The ductus arteriosus is normally patent in the fetus and closes after birth in full term infants during the first 10-18 hours of life. In low birth neonates the ductus does not close resulting in excessive blood flow to the lungs causing congestion and respiratory distress). Post operatively an order was written for Lasix ((diuretic medication; excessive dosing can initially cause a crisis situation with volume depletion, electrolyte imbalance and hypotension; long term effects can include renal impairment and ototoxicity) 6.1 milligrams (mg) to be administered once via intravenous. Nurse #1 signed off and transcribed the order onto the medication administration record as Lasix 6.1 mg once via intravenous now- 1mg/kilogram (kg). Nurse #2, the oncoming nurse, co-signed the order with Nurse #1. and then Nurse #2 administered the Lasix to Infant #1 via slow intravenous push. There were no hemodynamic changes throughout the shift and Infant #1 voided approximately milliliters (ml) of urine.

The report indicated that an investigation was conducted by the Hospital that included a multidisciplinary review. Infant #1 whose weight was 610 grams at the time the Lasix was ordered, should have received 0.61 mg and not 6.1 mg. The investigation determined the medication error occurred because the order was written and transcribed incorrectly and policies were not followed.

A multidisciplinary meeting was held at which time a corrective action plan was developed.

The following actions were implemented: 1) counseling the Resident regarding the medication error and the correct prescription format (done 9/14/10); 2) re-educate the medical staff regarding the medication ordering policy (9/30/10 and 10/1/10); 3) instituting a hard stop policy for pharmacy if a weight-based medication order does not have the weight-based dose written (send via high alert electronic mail sent 9/8/10 to all pharmacists, verbalized at the staff meeting on 9/9/10, and meeting minutes distributed on 9/10/10); 4) consider use of intravenous pump with appropriate equipment for NICU medication administrations (Lasix was the only medication pushed; now being given via the pump); 5) Nurses #1, #2, and #3 received disciplinary actions for their role in the medication error and were given individual performance improvement plans to complete, and 6) Nurses #1, #2, and #3 reported they were using calculators for all weight-based orders as were other NICU nurses.

At the time of the survey the following actions had not been implemented: 1) re-education of clinical staff that the current weight of the neonate must documented on the physician order sheet (starting 10/5/10); 2) re-education of nursing staff regarding chain of command when there is a lack of clarity or conflict regarding medication orders (date not identified); 3) prepare a summary of this case to be used as a teaching file (no date available); 4) evaluate label load in the automated system when a medication should have a weight dose written (no date available), and 5) Nurses #1, #2, and #3 were going to develop an educational program regarding medication administration to be presented to the NICU staff..

Review of the corrective action plan indicated that it did not include a mechanism to ensure that there was follow-up quality monitoring to ensure effectiveness of the corrective actions.

Based on documentation review, the Hospital failed to ensure that urine outputs were accurately recorded for one of one infant patients (Infant #1).

Findings included:

Please refer to A-0288 for further information.

The Policy/Procedure titled NICU/CCN Flow Records indicated that urine output was calculated by measuring the urine in the diaper and documented in milliliters.

Review of Infant #1's NICU Patient Progress Records, dated 8/22/10 to 9/3/10, indicated that nursing frequently documented urine output as voiding, wet diapers, or adequate and did not document the total milliliters voided.