HospitalInspections.org

Based on observation, record review and interview, the facility failed to ensure that the nursing staff followed policies and procedures for an effective administration of drugs as evidenced on 1 (SP#1) of 10 sampled patients who received a medication that was not ordered by the physician resulting to respiratory failure.

Findings Include:

Clinical record review conducted on 8/10 and 11/2010 revealed that SP#1(focus of
investigation) is a 79 year old male with history of end stage renal disease (ESRD), on
hemodialysis, diabetes, hypertension, and history of prostate cancer. Patient was in the
dialysis center on 7/29/10 when he had severe shortness of breath. Patient was transported
to the facility ' s Emergency Room (ER)placed on respiratory bipap (bilevel positive air
pressure) a machine that helps users breathe more easily. Patient was ultimately admitted to
ICU (Intensive Care Unit). Interdisciplinary progress notes dated 7/30/10 showed that at
0730 AM patient was received by the morning shift RN (ICU RN#5)resting in bed on
Bipap machine. Assessment was done and noted patient to be complaining ofabdominal gas
discomfort at the level of 6/10 pain scale. At 0850 AM ICU RN#5 noted that patient was
found unresponsive and monitor was showing asystole. Code blue was called and ACLS
(Advanced Cardiac Life Support) protocol was implemented. Emergency Response Record
showed that SP#1was coded twice on 7/30/10 (0850 AM and 0921AM). SP#1 was
intubated by the anesthesiologist on the first code and was revived with junctional rhythm.
Patient coded again at 0921AM and was revived again and placed on the ventilator.
Interview with the ICU Director on 08/11/10 revealed that ICU RN#5 reported to her that he medicated the patient of what he thought was intravenous Famotidine (pepcid) at around 0820 AM to relieve the patient of abdominal discomfort but must have made a mistake of giving the correct medication and showed the ICU Nurse Director an empty vial of " Pancuronium " . The ICU RN#5 told the ICU Director that he thought he scanned the medication that is why he was able to give the medication. The incident was immediately reported to the Director of Risk Management and the nurse involved was sent home. SP#1 was reassigned to another nurse. The physician was notified of an adverse medication error. CEO, CNO, Chief Compliance Officer and Pharmacy Director were also notified of the incident. Root Cause Analysis was done and found out that the Famotidine and Pancuronium were available as a floor stock in ICU/CCU and both came in similar size vial and both are stored in the refrigerator. First action taken after sending the nurse home was to remove check all pharmacy floor stock on all the units and remove all the Pancuronium floor stock. Pancuronium will only be available as part of the Code Blue cart.
Pulmonary consult notes dated 07/30/10 that at around 1100AM , physician had a long
conversation with the patient ' s son and explained that the reason for the patient to
decompensate that morning may have been related to a mismatch in medications where
instead of " Pepcid " patient received " Pancuronium " .
The ICU Nurse Director noted that on 7/30/10 a full disclosure was done with the wife and
family. During the tour of ICU, observation of SP#1 revealed patient to be intubated and
connected to a ventilator. Patient was non-responsive.
A demonstration of the pyxis system using the omnicell product showed that only nurses with
their own special loginidentification can the access the pyxis and sign out medications for
their patients. The Director of Pharmacy stated that a physician ' s order is needed in
order to process the order and placed on the system. Pharmacy Director stated that it will
be difficult to commit a medication error if the nurse will follow the established safe guards in
the system. The Pharmacy Director showed that system will show what medications the
patient is on and will only open the box that a medicine is intended for the patient. The
system will also asked a medication count and ask the nurse how many medications are left.
The nurse needs to scan the medication to be given in order for the safeguard to work. In
case of emergencies the system has an override or bypass. The system has 2 stages. First
the nurse must log in and enter the patient ' s name the nurse wants to give the medicine. If
the nurse tries to enter a medication that the patient is not on, the system will not open.
Once the nurse enters the correct patient and remove the medicine for administration, the
nurse needs to scan the medication which would indicate the time the medication can be
given and tells the nurse that the patient has the medication ordered by the physician. The
nurse then will go to the bedside with the Bridge (computerized Medication Cart) and scan
the patient ' s arm band for identification to match with the medication order. If the
medication is not ordered, the computer will immediately warn the nurse that the medication
is not ordered for a particular patient and the nurse must stop and check and determine what
was the discrepancy. There are times when the barcode cannot be properly scanned and
if medication is not given, a second signature is required. There are medications like insulin
that requires 2 signatures every time it is administered. For a wrong medication to be
administered to patient, the nurse must have failed to look and read what medication he/she
was taking in the lock refrigerator, failed to scan to determine the right count for the
medication, failed to match the patient's ID with the scanned medication. The nurse failed to
follow any of the safeguards that were in place.
Pharmacy services was unable to provide any evidence to show that a periodic review of the
floor stock medications are conducted and reviewed with a member of the medical staff to
justify the continous need of the medication "Pancuronium" as a floor stock. There was no
evidence to show that the Pharmacist provided additional safeguards to prevent medication
administration error by separating the "Pancuronium" from medication like "Pepcid" that came
in a similar vial as the Pancuronium.

Interview with the CNO, Risk Manager and Director of ICU on 8/11/10 revealed that the
facility has implemented several corrective actions. The following were done:
1. The Nurse was removed from the care area immediately and was sent home.
2. Physician was notified of the adverse medication error
3. Pancuronium was removed from all floor stock and be available on in the Code Cart. Pharmacy will monitor the Pancuronium usage since the life span is good only for 30 days when not refrigerated.
4. Full Family Disclosure
5. Risk Management, Quality Management, CEO, CNO, Compliance Officer, Pharmacy Services, Anesthesia Services were immediately informed of the incident
6. Staff Meeting was held twice immediately in the ICU/CCU. Hospital wide staff meeting in other units are already ongoing and will continue until everyone is made aware of the problem with medication error and the monitoring program that is put in place
7. Pharmacy has reviewed all the available medications as floor stock and made a determination on what is needed and remove drugs that are potential harmful.
8. Root cause analysis was done and on going measures are in place and on going
9. Nurse under indefinite suspension. Nurse was also referred to EAP (Employee Assistance Program)
10. Nurse was reported to Medical Quality Assurance for nursing practice
11. A code 15 incident report was done
12. The Joint Commission will be notified of the incident as a Sentinel Event
13. Ongoing Monitoring by Pharmacy in cooperation with Nursing Directors regarding: Pharmacy Discrepancy Report, Med Errors Prevented Summary, and Barcode Compliance Report.
14. Nursing Services - ongoing medication administration compliance monitoring. Spot check to be done if nurses are following the safeguards intended for medication administration.
15. Nursing Services - to review compliance report and counsel nurses and or discipline as necessary.
16. Pharmacy to ensure that Barcodes are printed properly to avoid scanning errors.
17. Medication error issues have been reported to quality assurance and scheduled for discussion. Corrective action plan are in place and ongoing


Barcode Compliance report dated 8/4 to 8/10/2010 for the ICU/CCU showed 4 nurses who are below 88% complaince in ensuring medications are scanned prior to administration. Investigation was still ongoing as to the cause of inability to scan.

Based on observation, record review and interview, the facility failed to ensure that the pharmacy evaluate and monitor drug delivery system including storage, appropriateness of drugs available as floor stock of potential for medication error as as evidenced on 1 (SP#1) of 10 sampled patients who received a medication that was not ordered by the physician resulting to respiratory failure.

Findings Include:

Clinical record review conducted on 8/10 and 11/2010 revealed that SP#1(focus of
investigation) is a 79 year old male with history of end stage renal disease (ESRD), on
hemodialysis, diabetes, hypertension, and history of prostate cancer. Patient was in the
dialysis center on 7/29/10 when he had severe shortness of breath. Patient was transported
to the facility ' s Emergency Room (ER)placed on respiratory bipap (bilevel positive air
pressure) a machine that helps users breathe more easily. Patient was ultimately admitted to
ICU (Intensive Care Unit). Interdisciplinary progress notes dated 7/30/10 showed that at
0730 AM patient was received by the morning shift RN (ICU RN#5)resting in bed on
Bipap machine. Assessment was done and noted patient to be complaining ofabdominal gas
discomfort at the level of 6/10 pain scale. At 0850 AM ICU RN#5 noted that patient was
found unresponsive and monitor was showing asystole. Code blue was called and ACLS
(Advanced Cardiac Life Support) protocol was implemented. Emergency Response Record
showed that SP#1was coded twice on 7/30/10 (0850 AM and 0921AM). SP#1 was
intubated by the anesthesiologist on the first code and was revived with junctional rhythm.
Patient coded again at 0921AM and was revived again and placed on the ventilator.
Interview with the ICU Director on 08/11/10 revealed that ICU RN#5 reported to her that he medicated the patient of what he thought was intravenous Famotidine (pepcid) at around 0820 AM to relieve the patient of abdominal discomfort but must have made a mistake of giving the correct medication and showed the ICU Nurse Director an empty vial of " Pancuronium " . The ICU RN#5 told the ICU Director that he thought he scanned the medication that is why he was able to give the medication. The incident was immediately reported to the Director of Risk Management and the nurse involved was sent home. SP#1 was reassigned to another nurse. The physician was notified of an adverse medication error. CEO, CNO, Chief Compliance Officer and Pharmacy Director were also notified of the incident. Root Cause Analysis was done and found out that the Famotidine and Pancuronium were available as a floor stock in ICU/CCU and both came in similar size vial and both are stored in the refrigerator. First action taken after sending the nurse home was to remove check all pharmacy floor stock on all the units and remove all the Pancuronium floor stock. Pancuronium will only be available as part of the Code Blue cart.
Pulmonary consult notes dated 07/30/10 that at around 1100AM , physician had a long
conversation with the patient ' s son and explained that the reason for the patient to
decompensate that morning may have been related to a mismatch in medications where
instead of " Pepcid " patient received " Pancuronium " .
The ICU Nurse Director noted that on 7/30/10 a full disclosure was done with the wife and
family. During the tour of ICU, observation of SP#1 revealed patient to be intubated and
connected to a ventilator. Patient was non-responsive.
A demonstration of the pyxis system using the omnicell product showed that only nurses with
their own special loginidentification can the access the pyxis and sign out medications for
their patients. The Director of Pharmacy stated that a physician ' s order is needed in
order to process the order and placed on the system. Pharmacy Director stated that it will
be difficult to commit a medication error if the nurse will follow the established safe guards in
the system. The Pharmacy Director showed that system will show what medications the
patient is on and will only open the box that a medicine is intended for the patient. The
system will also asked a medication count and ask the nurse how many medications are left.
The nurse needs to scan the medication to be given in order for the safeguard to work. In
case of emergencies the system has an override or bypass. The system has 2 stages. First
the nurse must log in and enter the patient ' s name the nurse wants to give the medicine. If
the nurse tries to enter a medication that the patient is not on, the system will not open.
Once the nurse enters the correct patient and remove the medicine for administration, the
nurse needs to scan the medication which would indicate the time the medication can be
given and tells the nurse that the patient has the medication ordered by the physician. The
nurse then will go to the bedside with the Bridge (computerized Medication Cart) and scan
the patient ' s arm band for identification to match with the medication order. If the
medication is not ordered, the computer will immediately warn the nurse that the medication
is not ordered for a particular patient and the nurse must stop and check and determine what
was the discrepancy. There are times when the barcode cannot be properly scanned and
if medication is not given, a second signature is required. There are medications like insulin
that requires 2 signatures every time it is administered. For a wrong medication to be
administered to patient, the nurse must have failed to look and read what medication he/she
was taking in the lock refrigerator, failed to scan to determine the right count for the
medication, failed to match the patient's ID with the scanned medication. The nurse failed to
follow any of the safeguards that were in place.
Pharmacy services was unable to provide any evidence to show that a periodic review of the
floor stock medications are conducted and reviewed with a member of the medical staff to
justify the continous need of the medication "Pancuronium" as a floor stock. There was no
evidence to show that the Pharmacist provided additional safeguards to prevent medication
administration error by separating the "Pancuronium" from medication like "Pepcid" that came
in a similar vial as the Pancuronium.

Interview with the CNO, Risk Manager and Director of ICU on 8/11/10 revealed that the
facility has implemented several corrective actions. The following were done:
1. The Nurse was removed from the care area immediately and was sent home.
2. Physician was notified of the adverse medication error
3. Pancuronium was removed from all floor stock and be available on in the Code Cart. Pharmacy will monitor the Pancuronium usage since the life span is good only for 30 days when not refrigerated.
4. Full Family Disclosure
5. Risk Management, Quality Management, CEO, CNO, Compliance Officer, Pharmacy Services, Anesthesia Services were immediately informed of the incident
6. Staff Meeting was held twice immediately in the ICU/CCU. Hospital wide staff meeting in other units are already ongoing and will continue until everyone is made aware of the problem with medication error and the monitoring program that is put in place
7. Pharmacy has reviewed all the available medications as floor stock and made a determination on what is needed and remove drugs that are potential harmful.
8. Root cause analysis was done and on going measures are in place and on going
9. Nurse under indefinite suspension. Nurse was also referred to EAP (Employee Assistance Program)
10. Nurse was reported to Medical Quality Assurance for nursing practice
11. A code 15 incident report was done
12. The Joint Commission will be notified of the incident as a Sentinel Event
13. Ongoing Monitoring by Pharmacy in cooperation with Nursing Directors regarding: Pharmacy Discrepancy Report, Med Errors Prevented Summary, and Barcode Compliance Report.
14. Nursing Services - ongoing medication administration compliance monitoring. Spot check to be done if nurses are following the safeguards intended for medication administration.
15. Nursing Services - to review compliance report and counsel nurses and or discipline as necessary.
16. Pharmacy to ensure that Barcodes are printed properly to avoid scanning errors.
17. Medication error issues have been reported to quality assurance and scheduled for discussion. Corrective action plan are in place and ongoing


Barcode Compliance report dated 8/4 to 8/10/2010 for the ICU/CCU showed 4 nurses who are below 88% complaince in ensuring medications are scanned prior to administration. Investigation was still ongoing as to the cause of inability to scan.

Based on observation, record review and interview, the facility failed to ensure that the nursing staff followed policies and procedures for an effective administration of drugs as evidenced on 1 (SP#1) of 10 sampled patients who received a medication that was not ordered by the physician resulting to respiratory failure.

Findings Include:

Clinical record review conducted on 8/10 and 11/2010 revealed that SP#1(focus of
investigation) is a 79 year old male with history of end stage renal disease (ESRD), on
hemodialysis, diabetes, hypertension, and history of prostate cancer. Patient was in the
dialysis center on 7/29/10 when he had severe shortness of breath. Patient was transported
to the facility ' s Emergency Room (ER)placed on respiratory bipap (bilevel positive air
pressure) a machine that helps users breathe more easily. Patient was ultimately admitted to
ICU (Intensive Care Unit). Interdisciplinary progress notes dated 7/30/10 showed that at
0730 AM patient was received by the morning shift RN (ICU RN#5)resting in bed on
Bipap machine. Assessment was done and noted patient to be complaining ofabdominal gas
discomfort at the level of 6/10 pain scale. At 0850 AM ICU RN#5 noted that patient was
found unresponsive and monitor was showing asystole. Code blue was called and ACLS
(Advanced Cardiac Life Support) protocol was implemented. Emergency Response Record
showed that SP#1was coded twice on 7/30/10 (0850 AM and 0921AM). SP#1 was
intubated by the anesthesiologist on the first code and was revived with junctional rhythm.
Patient coded again at 0921AM and was revived again and placed on the ventilator.
Interview with the ICU Director on 08/11/10 revealed that ICU RN#5 reported to her that he medicated the patient of what he thought was intravenous Famotidine (pepcid) at around 0820 AM to relieve the patient of abdominal discomfort but must have made a mistake of giving the correct medication and showed the ICU Nurse Director an empty vial of " Pancuronium " . The ICU RN#5 told the ICU Director that he thought he scanned the medication that is why he was able to give the medication. The incident was immediately reported to the Director of Risk Management and the nurse involved was sent home. SP#1 was reassigned to another nurse. The physician was notified of an adverse medication error. CEO, CNO, Chief Compliance Officer and Pharmacy Director were also notified of the incident. Root Cause Analysis was done and found out that the Famotidine and Pancuronium were available as a floor stock in ICU/CCU and both came in similar size vial and both are stored in the refrigerator. First action taken after sending the nurse home was to remove check all pharmacy floor stock on all the units and remove all the Pancuronium floor stock. Pancuronium will only be available as part of the Code Blue cart.
Pulmonary consult notes dated 07/30/10 that at around 1100AM , physician had a long
conversation with the patient ' s son and explained that the reason for the patient to
decompensate that morning may have been related to a mismatch in medications where
instead of " Pepcid " patient received " Pancuronium " .
The ICU Nurse Director noted that on 7/30/10 a full disclosure was done with the wife and
family. During the tour of ICU, observation of SP#1 revealed patient to be intubated and
connected to a ventilator. Patient was non-responsive.
A demonstration of the pyxis system using the omnicell product showed that only nurses with
their own special loginidentification can the access the pyxis and sign out medications for
their patients. The Director of Pharmacy stated that a physician ' s order is needed in
order to process the order and placed on the system. Pharmacy Director stated that it will
be difficult to commit a medication error if the nurse will follow the established safe guards in
the system. The Pharmacy Director showed that system will show what medications the
patient is on and will only open the box that a medicine is intended for the patient. The
system will also asked a medication count and ask the nurse how many medications are left.
The nurse needs to scan the medication to be given in order for the safeguard to work. In
case of emergencies the system has an override or bypass. The system has 2 stages. First
the nurse must log in and enter the patient ' s name the nurse wants to give the medicine. If
the nurse tries to enter a medication that the patient is not on, the system will not open.
Once the nurse enters the correct patient and remove the medicine for administration, the
nurse needs to scan the medication which would indicate the time the medication can be
given and tells the nurse that the patient has the medication ordered by the physician. The
nurse then will go to the bedside with the Bridge (computerized Medication Cart) and scan
the patient ' s arm band for identification to match with the medication order. If the
medication is not ordered, the computer will immediately warn the nurse that the medication
is not ordered for a particular patient and the nurse must stop and check and determine what
was the discrepancy. There are times when the barcode cannot be properly scanned and
if medication is not given, a second signature is required. There are medications like insulin
that requires 2 signatures every time it is administered. For a wrong medication to be
administered to patient, the nurse must have failed to look and read what medication he/she
was taking in the lock refrigerator, failed to scan to determine the right count for the
medication, failed to match the patient's ID with the scanned medication. The nurse failed to
follow any of the safeguards that were in place.
Pharmacy services was unable to provide any evidence to show that a periodic review of the
floor stock medications are conducted and reviewed with a member of the medical staff to
justify the continous need of the medication "Pancuronium" as a floor stock. There was no
evidence to show that the Pharmacist provided additional safeguards to prevent medication
administration error by separating the "Pancuronium" from medication like "Pepcid" that came
in a similar vial as the Pancuronium.

Interview with the CNO, Risk Manager and Director of ICU on 8/11/10 revealed that the
facility has implemented several corrective actions. The following were done:
1. The Nurse was removed from the care area immediately and was sent home.
2. Physician was notified of the adverse medication error
3. Pancuronium was removed from all floor stock and be available on in the Code Cart. Pharmacy will monitor the Pancuronium usage since the life span is good only for 30 days when not refrigerated.
4. Full Family Disclosure
5. Risk Management, Quality Management, CEO, CNO, Compliance Officer, Pharmacy Services, Anesthesia Services were immediately informed of the incident
6. Staff Meeting was held twice immediately in the ICU/CCU. Hospital wide staff meeting in other units are already ongoing and will continue until everyone is made aware of the problem with medication error and the monitoring program that is put in place
7. Pharmacy has reviewed all the available medications as floor stock and made a determination on what is needed and remove drugs that are potential harmful.
8. Root cause analysis was done and on going measures are in place and on going
9. Nurse under indefinite suspension. Nurse was also referred to EAP (Employee Assistance Program)
10. Nurse was reported to Medical Quality Assurance for nursing practice
11. A code 15 incident report was done
12. The Joint Commission will be notified of the incident as a Sentinel Event
13. Ongoing Monitoring by Pharmacy in cooperation with Nursing Directors regarding: Pharmacy Discrepancy Report, Med Errors Prevented Summary, and Barcode Compliance Report.
14. Nursing Services - ongoing medication administration compliance monitoring. Spot check to be done if nurses are following the safeguards intended for medication administration.
15. Nursing Services - to review compliance report and counsel nurses and or discipline as necessary.
16. Pharmacy to ensure that Barcodes are printed properly to avoid scanning errors.
17. Medication error issues have been reported to quality assurance and scheduled for discussion. Corrective action plan are in place and ongoing


Barcode Compliance report dated 8/4 to 8/10/2010 for the ICU/CCU showed 4 nurses who are below 88% complaince in ensuring medications are scanned prior to administration. Investigation was still ongoing as to the cause of inability to scan.

Based on observation, record review and interview, the facility failed to ensure that the pharmacy evaluate and monitor drug delivery system including storage, appropriateness of drugs available as floor stock of potential for medication error as as evidenced on 1 (SP#1) of 10 sampled patients who received a medication that was not ordered by the physician resulting to respiratory failure.

Findings Include:

Clinical record review conducted on 8/10 and 11/2010 revealed that SP#1(focus of
investigation) is a 79 year old male with history of end stage renal disease (ESRD), on
hemodialysis, diabetes, hypertension, and history of prostate cancer. Patient was in the
dialysis center on 7/29/10 when he had severe shortness of breath. Patient was transported
to the facility ' s Emergency Room (ER)placed on respiratory bipap (bilevel positive air
pressure) a machine that helps users breathe more easily. Patient was ultimately admitted to
ICU (Intensive Care Unit). Interdisciplinary progress notes dated 7/30/10 showed that at
0730 AM patient was received by the morning shift RN (ICU RN#5)resting in bed on
Bipap machine. Assessment was done and noted patient to be complaining ofabdominal gas
discomfort at the level of 6/10 pain scale. At 0850 AM ICU RN#5 noted that patient was
found unresponsive and monitor was showing asystole. Code blue was called and ACLS
(Advanced Cardiac Life Support) protocol was implemented. Emergency Response Record
showed that SP#1was coded twice on 7/30/10 (0850 AM and 0921AM). SP#1 was
intubated by the anesthesiologist on the first code and was revived with junctional rhythm.
Patient coded again at 0921AM and was revived again and placed on the ventilator.
Interview with the ICU Director on 08/11/10 revealed that ICU RN#5 reported to her that he medicated the patient of what he thought was intravenous Famotidine (pepcid) at around 0820 AM to relieve the patient of abdominal discomfort but must have made a mistake of giving the correct medication and showed the ICU Nurse Director an empty vial of " Pancuronium " . The ICU RN#5 told the ICU Director that he thought he scanned the medication that is why he was able to give the medication. The incident was immediately reported to the Director of Risk Management and the nurse involved was sent home. SP#1 was reassigned to another nurse. The physician was notified of an adverse medication error. CEO, CNO, Chief Compliance Officer and Pharmacy Director were also notified of the incident. Root Cause Analysis was done and found out that the Famotidine and Pancuronium were available as a floor stock in ICU/CCU and both came in similar size vial and both are stored in the refrigerator. First action taken after sending the nurse home was to remove check all pharmacy floor stock on all the units and remove all the Pancuronium floor stock. Pancuronium will only be available as part of the Code Blue cart.
Pulmonary consult notes dated 07/30/10 that at around 1100AM , physician had a long
conversation with the patient ' s son and explained that the reason for the patient to
decompensate that morning may have been related to a mismatch in medications where
instead of " Pepcid " patient received " Pancuronium " .
The ICU Nurse Director noted that on 7/30/10 a full disclosure was done with the wife and
family. During the tour of ICU, observation of SP#1 revealed patient to be intubated and
connected to a ventilator. Patient was non-responsive.
A demonstration of the pyxis system using the omnicell product showed that only nurses with
their own special loginidentification can the access the pyxis and sign out medications for
their patients. The Director of Pharmacy stated that a physician ' s order is needed in
order to process the order and placed on the system. Pharmacy Director stated that it will
be difficult to commit a medication error if the nurse will follow the established safe guards in
the system. The Pharmacy Director showed that system will show what medications the
patient is on and will only open the box that a medicine is intended for the patient. The
system will also asked a medication count and ask the nurse how many medications are left.
The nurse needs to scan the medication to be given in order for the safeguard to work. In
case of emergencies the system has an override or bypass. The system has 2 stages. First
the nurse must log in and enter the patient ' s name the nurse wants to give the medicine. If
the nurse tries to enter a medication that the patient is not on, the system will not open.
Once the nurse enters the correct patient and remove the medicine for administration, the
nurse needs to scan the medication which would indicate the time the medication can be
given and tells the nurse that the patient has the medication ordered by the physician. The
nurse then will go to the bedside with the Bridge (computerized Medication Cart) and scan
the patient ' s arm band for identification to match with the medication order. If the
medication is not ordered, the computer will immediately warn the nurse that the medication
is not ordered for a particular patient and the nurse must stop and check and determine what
was the discrepancy. There are times when the barcode cannot be properly scanned and
if medication is not given, a second signature is required. There are medications like insulin
that requires 2 signatures every time it is administered. For a wrong medication to be
administered to patient, the nurse must have failed to look and read what medication he/she
was taking in the lock refrigerator, failed to scan to determine the right count for the
medication, failed to match the patient's ID with the scanned medication. The nurse failed to
follow any of the safeguards that were in place.
Pharmacy services was unable to provide any evidence to show that a periodic review of the
floor stock medications are conducted and reviewed with a member of the medical staff to
justify the continous need of the medication "Pancuronium" as a floor stock. There was no
evidence to show that the Pharmacist provided additional safeguards to prevent medication
administration error by separating the "Pancuronium" from medication like "Pepcid" that came
in a similar vial as the Pancuronium.

Interview with the CNO, Risk Manager and Director of ICU on 8/11/10 revealed that the
facility has implemented several corrective actions. The following were done:
1. The Nurse was removed from the care area immediately and was sent home.
2. Physician was notified of the adverse medication error
3. Pancuronium was removed from all floor stock and be available on in the Code Cart. Pharmacy will monitor the Pancuronium usage since the life span is good only for 30 days when not refrigerated.
4. Full Family Disclosure
5. Risk Management, Quality Management, CEO, CNO, Compliance Officer, Pharmacy Services, Anesthesia Services were immediately informed of the incident
6. Staff Meeting was held twice immediately in the ICU/CCU. Hospital wide staff meeting in other units are already ongoing and will continue until everyone is made aware of the problem with medication error and the monitoring program that is put in place
7. Pharmacy has reviewed all the available medications as floor stock and made a determination on what is needed and remove drugs that are potential harmful.
8. Root cause analysis was done and on going measures are in place and on going
9. Nurse under indefinite suspension. Nurse was also referred to EAP (Employee Assistance Program)
10. Nurse was reported to Medical Quality Assurance for nursing practice
11. A code 15 incident report was done
12. The Joint Commission will be notified of the incident as a Sentinel Event
13. Ongoing Monitoring by Pharmacy in cooperation with Nursing Directors regarding: Pharmacy Discrepancy Report, Med Errors Prevented Summary, and Barcode Compliance Report.
14. Nursing Services - ongoing medication administration compliance monitoring. Spot check to be done if nurses are following the safeguards intended for medication administration.
15. Nursing Services - to review compliance report and counsel nurses and or discipline as necessary.
16. Pharmacy to ensure that Barcodes are printed properly to avoid scanning errors.
17. Medication error issues have been reported to quality assurance and scheduled for discussion. Corrective action plan are in place and ongoing


Barcode Compliance report dated 8/4 to 8/10/2010 for the ICU/CCU showed 4 nurses who are below 88% complaince in ensuring medications are scanned prior to administration. Investigation was still ongoing as to the cause of inability to scan.