HospitalInspections.org

45769

Based on record review and staff interviews it has been determined that the hospital failed to ensure safety practices are consistent with recognized standards of practice for anesthesia care for 1 of 6 patients reviewed who received the wrong medication during a surgical procedure (Patient ID #1). Refer to A-1002

Based on record review and staff interviews it has been determined that the hospital failed to provide Anesthesia services that are consistent with recognized standards for anesthesia care and safety practices for 1 of 6 patients reviewed (Patient ID #1) , related to the incorrect medication administration of a vasopressor (drug that causes constriction of the blood vessels), that was intended to be an antiemetic (drug used to prevent nausea and vomiting).

Findings are as follows:

A report submitted to the Rhode Island Department of Health on 12/4/2023 by the hospital's Risk Manager revealed that on 11/28/2023 a patient undergoing surgery received a dose of IV Phenylephrine, when IV Zofran was intended resulting in hypertension (increased blood pressure). The patient required additional treatment.

Review of the hospital's policy titled, "Medication Administration" states in part,
...Five Rights of Medication Administration Practice
1. Right Patient
2. Right Medication: ensure that the medication being given matches what has been prescribed ...
3. Right Dose: Ensure that the dosage of the medication matches ...
4. Right Route
5. Right Time

...Before Administering Medications
For all medication administration, the individual administering the medication does the following:
1. Verifies the five rights ...
4. Visually inspects the medication ...

Record review for Patient ID #1 revealed an Operative Note Report dated 11/28/2023 at 7:30AM, indicating the patient underwent an elective robotic assisted laparoscopic (minimally invasive surgical technique) removal of a pelvic mass, right ovary, and fallopian tube. The note included: Complication(s): Hypertensive emergency following the incorrect IV medication administration.

Review of the OR medication list revealed Patient ID #1 received 10 mg(milligrams) of Phenylephrine IV (intravenous) at 12:07 PM.

Review of a Vascular Neurology Consult Note dated 11/28/2023 at 2:42PM stated the following, 80-year-old female admitted 11/28/2023, underwent laparoscopic removal ...She received Phenylephrine intraoperatively and her "systolic blood pressure shot to 250" ...

During a surveyor interview with the third year Anesthesia Resident, Staff A on 12/5/2023 at 2:00PM, she confirmed that she was assigned to Patient ID #1' s OR case. Staff A stated that on 11/28 at 12:05PM, she removed two medications for Patient ID #1, one vial Sugammadex 400 mg (drug used to reverse anesthesia agents) and one vial of Zofran 4mg (antiemetic). Staff A stated that she removed both medications from the top drawer of the anesthesia omni cell (secured storage cabinet). She then stated that she drew up each medication vial into a separate syringe and administered both into Patient ID #1's intravenous line. Staff A stated that she noticed that Patient ID #1's blood pressure was elevated following the administration of these medications and notified her attending physician. At that time, the two medication vials were reviewed with the attending physician, and it was discovered that the patient did not receive Zofran as intended but had received Phenylephrine in error. Staff A acknowledged that she did not inspect the medication vial of Phenylephrine close enough to assure that it was the right medication. She did acknowledge she had received education regarding the 5 rights of medication administration.