HospitalInspections.org

Based on document review and staff interview it was determined the Registered Nurse (RN) failed to ensure patient medication was labeled for the correct patient in one (1) of ten (10) medical records reviewed of patients who received intravenous fluids (patient #2). This failure creates the potential for all patients to receive medication labeled to the wrong patient with possible negative outcomes or adverse events.

Findings include:

1. An interview was conducted with RN #1 on 3/1/16 at 2:20 p.m. When asked if she remembered patient #2 she stated, "Yes". When asked if she remembered a complaint made by the family about another patient's name being on patient #2's IV bag she stated, in part: "Yes, I was walking by his room and one of his daughters told me he had another patient's fluids hanging. When I checked the patient and the label on the fluids they did not match. I turned it off, checked the chart for the order, and saw it was the right solution and right rate. I don't know who hung the fluids but I removed the label and placed the right patient label on the bag." When shown a photo of the fluids she then acknowledged she must not have removed patient #6's label. It should be noted RN #1 was not the nurse assigned to care for patient #2.

2. Review of the policy titled, "Medication Safety Policies", last revised 11/15, states, in part: "If any error in medications has been made or there is a drug reaction, the physician ordering the medication and the supervisor will be notified immediately. An online Incident Report must be completed...Each time a medication is given, the patient's identification will be checked and the identification band on wrist with the E-MAR sheet to insure accuracy of the patient and medicine."

3. Review of the policy titled, "Incident Reporting", last revised 10/12, states, in part: "Any happening which is not consistent with the routine operation of the hospital or the routine care of a patient...shall be recorded in an incident report online."

4. Review of the incident log for 11/15 revealed no incident was filed or reported for the occurrence on 11/29/15.

5. An interview was conducted on 3/1/16 at 10:40 a.m. with the Assistant Director of Nursing and she concurred with the above findings.