HospitalInspections.org

Based on review of facility policy, medical record review, and interview, the facility failed to document and report a medication error related to one patient (#3) of nine patients reviewed.

The findings included:

Review of facility policy "Occurrence Reporting Guidelines for Patient; Visitor; and Facility Related Events" last reviewed on 9/5/13, revealed "...[named facility] encourages the reporting of occurrences with a primary focus on improving safety and quality through an analysis of system processes...occurrence reports are to be completed and submitted by the individual who observed or discovered the occurrence immediately following situation and stabilization of the patient or visitor...definitions: an occurrence is any event that occurs outside of normal operations of [named facility] that has resulted, or could result in harm to our patients...the terms occurrence, incident, and/or event are interchangeable...examples...medication errors...near misses...electronic reporting system...internet based tool for reporting and capturing occurrence information for tracking and analysis purposes...this electronic system provided for immediate routing to the appropriate leaders, along with Risk, Quality, and Patient Safety Management...the department leader is responsible for initiating the review and investigation process, assuring completion and accuracy of the report..."

Medical record review revealed Patient #3 was admitted to the Emergency Department (ED) on 1/25/15 at 12:09 PM with a chief complaint of a sore throat for over one week with nasal drainage. Further review of a nurse's assessment revealed "...complains of sore throat...pain is 5 out of 10 on the pain scale...throat is reddened had enlarged tonsils bilaterally..."

Medical record review of an electronic Physicians Documentation for Patient #3 dated 1/25/15 at 12:57 PM, revealed "...presents with sore throat..." Further review of a discharge diagnosis impression revealed "...Thrush, Candidal Stomatitis [inflammation of the mouth]..." and a prescription was given for Nystatin 100,000 units/ml (per milliliter) oral suspension (medication for oral thrush).

Medical record review revealed an electronic Physicians Order dated 1/25/15 at 12:37 PM, for Azithromycin (antibiotic) 1 gm (gram) PO (by mouth) and Rocephin (antibiotic) 500 mg (milligrams) IM (intramuscular).

Medical record review of the electronic Dispensed Medications revealed the patient received Azithromycin 1 gm PO and Rocephin 500 mg IM at 12:50 PM, which was given by the ED Registered Nurse (RN).

Medical record review revealed Patient #2 was admitted to the ED on 1/25/15 at 12:02 PM and was triaged by the ED Nurse at 12:42 PM with a chief complaint of her stomach hurting and her throat hurting for the last week.

Medical record review of an ED Physicians Documentation for Patient #2, dated 1/25/15 at 12:44 PM, revealed "...complains of sore throat that occurred gradually...pertinent positives...abdominal pain...Physical Exam...mouth is normal...posterior pharynx is normal..." Further review of a discharge diagnosis impression revealed "...Pelvic Inflammatory Disease [infection in the female reproductive organs]..."

Medical record review of an electronic ED Physicians order dated 1/25/15 at 1:24 PM, revealed an order for Azithromycin 1 gm PO and Rocephin 500 mg IM.

Medical record review of the electronic Dispensed Medications revealed the patient received Azithromycin 1 gm PO and Rocephin 500 mg IM at 2:07 PM which was given by the ED RN.

Interview with RN #1 on 4/22/15 at 12:40 PM, in the conference room, revealed the nurse provided care for Patient #3 and Patient #2 on 1/25/15. Further interview revealed the patients were mother and daughter and were placed in the same room to be seen by the physician. Further interview revealed "...there was an order written by the physician on 1/25/15 for [Patient #3] to receive Azithromycin 1gm PO and Rocephin 500 mg IM...the orders are electronically entered by the physician and then we get notification that there are medications ordered for a patient..." Further interview revealed "...I looked at the patient's record and noticed she did not have any allergies...when I went into the room to give the medications I looked at the identification bracelet to make sure I was giving the medication to the right patient ...the patient [#3] said to me I think those medications are for my daughter [Patient#2]...I told the patient I had the correct chart and the physician had ordered the medication for her...I then administered the medications to the patient [#3] and the patient did not say anything else..." Further interview revealed "...the physician went in the room to check on the patient [#2] and to see if she felt any better...the mother told him that she had received the medications and not her daughter...the physician then told both patients that he had ordered the medications on the wrong patient and the order was intended for the daughter [Patient #2]...he did tell the mother that the medications would not hurt her and may actually help her...he exited the room and then ordered the same medications for the daughter [Patient #2]...after the physician ordered the medications for the daughter I administered the medications..."

Interview with the ED Nurse Manager on 4/22/15 at 12:50 PM, in the conference room, revealed "...I talked to [Patient #3] on the phone...do not remember the date...she told me that she had received medications that were intended for her daughter [Patient #2] while in the ED on 1/25/15...she stated the physician had told her the medications were written on the wrong chart but the medications would not hurt her and would probably help her..." Further interview revealed "...I talked to the nurse about the situation and realized the nurse had not submitted an incident report...I told her she must submit the incident report..." Further interview revealed "...I spoke with the physician...he told me ordered the medications on the wrong patient but had talked to the patient [Patient #3] in the ED and told her the medication would not hurt her and would probably help her..."

Interview with the Director of Risk Management (RM) on 4/22/15 at 1:05 PM, in the conference room, revealed an incident report related to Patient #3 was initiated on 1/28/15 by RN #1. Further interview revealed "...the incident report indicated the physician had ordered medications for the wrong patient and the medications were administered to [Patient #3]..." Continued interview revealed "...the incident report indicated the patient [#3] had called the ED Nurse Manager..." Further interview confirmed "...any medication error should be reported at the time of the event...the nurse should fill the incident report out prior to completing the assigned shift..."

Interview with the ED Physician on 4/22/15 at 3:30 PM, in the ED Nurse's Station, revealed "...Azithromycin and Rocephin would not be indicated for a patient with a diagnosis Thrush...Nystatin 100,000 units would be appropriate for Thrush..."

Interview with RN #1 on 4/22/15 at 3:45 PM, in the ED Nurses Station, revealed "...I did not complete the incident report the day of the incident...I do not remember the day I completed the report...I did tell my charge nurse after we had realized the medications had been ordered for the wrong patient..."

Interview with the ED Nurse Manager on 4/22/15 at 4:00 PM, in the conference room, revealed "...when I was notified by the patient I looked for an incident report and realized that no report had been completed...I called the nurse and she completed the incident report on her next scheduled day to work..." Further interview confirmed the report should be completed when the incident occurred. Further interview confirmed the physician failed to document the medication error for patient #3 and the incident report was not completed in timely manner.