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Based on facility policy and medical record review, the hospital nursing staff failed to follow physician orders when administering medication [UBRELVY] for 1 of 1 patients. (Patient #3)

findings included:

On request, there was no incident report available for review for medication errors for Patient #3.

Review of the policy Medication Administration Nursing, last reviewed 01/2025 revealed POLICY. This policy provides guidelines for medication administration in a safe manner following established policies and procedures. ... PREPARATION. A. Review order, MAR [medication administration record], and comments for special instructions and order parameters. ..."

Closed medical record review on 03/04/2025 revealed Patient #3, a 74-year-old female who presented to the emergency department via emergency medical services on 11/20/2024 at 1452 for complaints of altered mental status and cough. Patient #3 was evaluated and admitted on 11/20/2024 at 1944 with a diagnosis of altered mental status [a deviation from a person's normal level of alertness, awareness and responsiveness], acute kidney injury [the kidneys fail to remove waste products from the blood affecting the nervous system], left lower pneumonia [infection in the lung], and toxic metabolic encephalopathy [brain dysfunction caused by metabolic disturbances, toxins, medications, or illicit drugs]. The History and Physical dated 11/20/2024 at 1845 by Nurse Practitioner #2 revealed "...Of note significant polypharmacy fentanyl [narcotic pain medication], oxycodone [narcotic pain medication], triazolam [used for difficulty sleeping], cyclobenzaprine [treats muscle spasms]. ... CT [Computed Tomography-a medical imaging technique that uses x-rays to create detailed cross-sectional images of the body.] of the head demonstrating no acute intracranial abnormality ...medication reconciliation incomplete; all appropriate home medications will be resumed once process complete." Review of the Medication Reconciliation completed on 11/21/2024 at 0041 by Certified Pharmacy Technician [CPHt] #1 revealed " ...confidence level in the medication list: Confident. Patient's daughter verified all medications with limited prompting of medication names, strengths, or directions. Patient's external fill history/bottles or medication list brought to hospital corresponds to the information provided by patient's daughter. Comments: medications, last doses, allergies, and pharmacy updated with Patient's daughter from [named] inpatient at bedside ..." Review of the Medication Reconciliation failed to reveal the medication UBRELVY [medication given for migraine headaches]. Review of Physician Medication Orders on 11/28/2024 at 1342 by Medical Doctor [MD] #3 revealed "UBRELVY tablet 50 mg [milligram] oral every 2 hours PRN [as needed] for migraine [severe headache], Admin [administration] instructions: Max [maximum] dose 200 mg/24 hours. ..." Patient #3 was administered UBRELVY 50 mg oral on 11/28/2024 at 1517 and on 11/28/2024 at 1758 by Registered Nurse [RN] #4, on 11/29/2024 at 1021, and on 11/30/2024 at 1623 by RN #5. The first medication order was completed/discontinued on 11/30/2024 at 1623. Review of the second Physician Order on 11/30/2024 at 2145 by Physician's Assistant [PA] #6 for UBRELVY 50mg oral once, was acknowledged by RN #7, and administered on 11/30/2024 at 2155. The second order for UBRELVY was completed 11/30/2024 at 2155. The third Physician Order for UBRELVY was placed on 12/01/2024 at 0747 by MD #8, "UBRELVY 50 mg oral, every 2 hours PRN for migraine; Admin instructions: may repeat dose x1 after 2 h. [hours]. Max 2 doses in 24 hours." Patient #3 was administered a dose on 12/01/2024 at 1149 by RN #9. UBRELVY was administered again on 12/03/2024 at 0630 by RN #10, 12/03/2024 at 2035 by RN #10, and 12/03/2024 at 2356 by RN #10. This medication administration exceeded the order of 2 doses in 24 hours for Patient #3. UBRELVY 50mg oral was administered on 12/06/2024 at 1549 by RN #11, again on 12/06/2024 at 2211 by RN #12, and a third time on 12/07/2024 at 0959 by RN #13. This medication administration exceeded the max dose of 2 times in 24 hours. The third Physician Order for UBRELVY was administered a total of 10 times 12/01/2024 through 12/07/2024 and was discontinued on 12/08/2024 at 1444 by MD #8. Patient #3 was discharged on 01/13/2025 at 1132 to a skilled nursing facility. Medical record review revealed 2 medication administrations that did not follow physician orders, 12/03/2024 at 2356, and 12/07/2024 at 0949.

Interview on 03/05/2025 at 1300 with RN #4 revealed "I remember the daughter. Her daughter called and requested this medication. I messaged [named MD #3]. The daughter was requested to bring in the medication. The pharmacy did get it. In [named electronic health record (EHR)], we have a pop-up box that appears if there's a flag to administration. But it may only prompt with narcotic medication. This was chronic pain, we addressed every shift. This daughter called repeatedly. We got the UBRELVY ordered." The interview revealed the EHR does not always flag with non-narcotic as needed medications.

Interview on 03/05/2025 at 1405 with the Pharm-D [Doctor of Pharmacy] revealed "orders flow, comments cannot flow. The nurse would have to look at the order. At the time the nurse scans the medication, the order was in view. This patient received more doses than ordered. There's not a hard stop with [named medication dispensing system] when med administration instructions are in the comment section. It sees the orders only. Not the comments. To change this in the [named medication dispensing system/ EHR would require multiple approvals, and considerable time to resolve. The interview revealed the hospital had not identified the medication errors for Patient #3. The interview revealed that the physician had put medication administration instructions in the comment section of the physician order, the EHR or Medication Dispensing System did not flag the nurse to warn for exceeded doses. Follow-up interview on 03/06/2025 at 1030 revealed "I spoke with named EHR, we have a new build planned for all non-narcotic PRN medications example; Tylenol limit in 24 hours. We will submit UBRELVY as well that was started yesterday. I met with leaders 03/04/2025 to escalate this extensive build process and was projected to completed by April 2025 ...Immediately, I have changed the order defaults to flag the nurse for every UBRELVY order ..." The interview revealed that 100% of all UBRELVY medication administrations will be flagged by the Medication Dispensing System/EHR for every administration to remind the nurse to check the parameters of the physician order until the permanent changes are completed in the EHR/Medication Dispensing System.

Telephone interview on 03/05/2025 at 1500 with MD #3 revealed he had reviewed the EHR prior to interview. UBREVLY was on the PRN list. She [patient #3] did receive it quite a bit. It was a home medication prescribed for chronic migraine headaches. This was a core issue during her stay. ...The medication was not on the formulary. [not a prescription medication a hospital would keep in stock for patient needs]. The max dose auto-populates when you select to order a medication in the system. UBRELVY was a neurology specific medication, and I felt it would help her continued headaches. ..." The interview revealed MD #3 was unaware any comments in the physician order would not flag the nurse when administering.

Interview on 03/06/2025 at 0907 with MD #8 revealed "I didn't write the order, I continued it. The daughter was requesting the maximum dose. The patient was under my care 12/07-10/2024, the daughter voiced concerns discussed with the neurologist. So, I discontinued the order. We will stop for a wash out period [a patient stops taking a specific medication or treatment to allow its effects to dissipate before starting a new intervention]. The daughter was concerned that the patient was getting medication 2 times a day for consecutive days, instead of 2 times a week. ..." The interview revealed MD #8 had stopped UBRELVY at the daughter's concerns. The interview revealed MD #8 was unaware Patient #3 had exceeded the UBRELVY dose that was ordered for her.

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