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Based on interviews and records reviewed, the Hospital failed to implement corrective actions and prevent a like occurrence from happening on 10 of 11 intensive care units after a patient was given intravenous medication inappropriately which resulted in the need for increased vasopressor support due to hypotensive reaction to the medication administration error.

Based on interviews and records reviewed the Hospital failed for one (Patient #2) patient of 10 sampled patients to provide implementation of preventative actions to all intensive care nurses after Patient #2 was given Propofol (an anesthetic medication used to cause relaxation and sleepiness before and during surgery and other medical procedures) intravenously per gravity when it was supposed to be in a pump for slower release of the medication resulting in the patient becoming hypotensive (low blood pressure) and requiring vasopressor support.

Patient #2 was admitted to the Hospital in 12/2020 for treatment of dizziness, fatigue and weakness. Patient #2 had a cardiac catheterization on 12/21/20 and then a coronary bypass surgery on 12/28/20. On 1/16/21, Patient #2 required an elective intubation due to increased work of breathing and left lung atelectasis. Patient #2 would require a Propofol infusion for sedation during the procedure. Once the patient was intubated, the Anesthesiologist noted the patient to be hypotensive out of proportion to the induction drugs administered. The patient was on intravenous Levophed (a medication used to treat life threatening low blood pressure) 2 micrograms per minute for the intubation, as planned. During the intubation procedure, the Levophed dosage had to be increased to 60 micrograms per minute due to hypotension documented at systolic BP of 93. Once the patient responded to the vasopressor (Levophed) it was discovered that the Propofol tubing had not been placed in an infusion pump, as required, and instead the clamp on the Propofol had been opened and the medication was administered by gravity, which resulted in the Propofol being administered too quickly resulting in hypotensive response.

In an interview on 4/28/21 at 9:00 A.M., the Director of Quality and Safety for Nursing Services said that the system's that the Hospital has in place for hanging medications wouldn't have helped because it was human error and not an error she has ever seen before. She said that the nurse did not use best practice when hanging multiple medications at one time.

The Director of Quality and Safety for Nursing Services said that the Hospital educated the nurses on the unit in which the error took place. The Director of Quality and Safety for Nursing Services said that the Hospital created a practice improvement recommendation list, as well as an online education to ensure the safety of IV medication administration, especially when working with multiple IV medications. She said they did not educate nursing staff in all of the ICU's because it was human error and not a system's error. The immediate action that took place on the unit was: three staff safety huddles, peer support, and computer-based education to the staff on Ellison 9 (a 16 bed licensed Intensive Care Unit to prevent a like occurrence from happening on the unit.

In an interview on 4/29/21 at 9:20 A.M., the Chief Compliance Officer said that the Hospital felt that this was so unlikely to happen again elsewhere and that they chose to only educate the one unit. The Hospital didn't feel it was a system error.

Review of the Hospital's license indicated that they are licensed for 101 Intensive Care Beds on Ellison 4, Blake 6, Blake 7, Blake 8, Blake 12 and Lunder 6. The Hospital is also licensed for 16 Coronary Care Unit beds on Ellison 9, 7 Burn Unit beds on Ellison 14, 44 Pediatric Service level I or II on Ellison 17 and 18, 13 Pediatric Intensive Care Unit Level III on Bigelow 6. These units all have the capability of providing the level of care required for Patient #2's procedure and the error could occur on any of the above listed units. Therefore, the Hospital failed to implement corrective actions and prevent a like occurrence from happening on 10 other units besides Ellison 9.