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Based on records reviewed and interviews the Hospital Quality Assessment & Performance Improvement (QAPI) Program activities failed, for one of ten sampled patients (Patient #1), to ensure effective corrective actions and implement these corrective actions hospital wide after Patient #1's medication overdose.

Findings include:

The Pediatric Intensive Care Unit (PICU) Progress Note, dated 3/22/18, indicated Patient #1 was admitted to the Pediatric Unit on 3/2/18. Patient #1 was scheduled for a surgical procedure on 3/21/18. Patient #1's medications were placed on hold prior to going to surgery and upon return to the floor Patient #1's medications were still on hold which included an order for Aspirin 40.5mg. The Note indicated the nurse caring for Patient #1 administered 405 mg of Aspirin (10 times the ordered dose) to Patient #1. The Progress Note indicated that Patient #1 required ICU level of care due to acute metabolic acidosis and was at risk for respiratory deterioration requiring intubation. Patient #1 required frequent assessments, non-invasive respiratory support and intravenous Sodium Bicarbonate.

Review of the document titled UMass Memorial Medical Center Policy: 2030 Medication Administration, indicates that clinical staff administering medication must bring the medication administration record/electronic equivalent/documentation record to the bedside along with the medication and verify at a minimum the five rights of safe medication administration per policy: right patient, right medication, right dose, right route, and right time.

The Surveyor interviewed the Nurse Manager of the Pediatric Unit on 7/2/18 at 9:55 A.M. The Nurse Manager said that when medications are on hold they need to be reviewed by the physician and then reviewed and released from hold by the nurse. The Nurse Manager said that on 3/21/18, Nurse #1 gave Patient #1 his/her medications but the medications were still on hold. The Nurse Manager said that medications on "Hold" are not able to be scanned and Nurse #1 did not scan them before administering the medications to Patient #1. The Nurse Manager said if Nurse#1 caring for Patient #1 had scanned the medications, the medication administration program would have alerted the nurse of the overdose. The Nurse Manager said that it's her expectation that the nurses use the scanner when administering medications and this is hospital policy.

The Surveyor interviewed Nurse #1 on 7/2/18 at 11:20 A.M. Nurse #1 said when Patient #1 returned to the floor after surgery, his/her medications were on hold. Nurse #1 said that Patient #1's medications were on hold because the physician caring for Patient #1 had yet to release them. Nurse #1 said that she did not understand the process for releasing a medication hold when patients returned from the Operating Room and she administered the medications without releasing them from hold or using the scanner. Nurse #1 said she misread the ordered dose of 40.5 mg and that she mistakenly administered the wrong dose of 405 mg (administering ten times the ordered dose).

As a response to this incident, the Nurse Manager said that she sent an email to be printed and signed by all nursing staff on the unit. The Nurse Manager said that the email indicated that medications should be reviewed and reconciled by a provider (physician) and nursing should then release the Medication Administration Record (MR) after the review process has been completed. The email also indicated that a number of multidisciplinary teams were working on the internal processes to help standardize "this and other new work flows" or words to that effect.

The Surveyor asked if the email was sent to all nurses in the hospital. The Nurse Manager said it was sent to just the pediatric nurses. When asked if there was any attempt to learn if other nurses in the hospital experienced misunderstandings or confusion with the medication release process, the Nurse Manager said no. When asked if the steps on how to release medications from the Medication Administration Record were reviewed with all the nurses after the incident, the Nurse Manager said no. The Nurse Manger said that she received electronic updates on the nurses use of the scanner but did not perform live audits to confirm that the proper process for medication administration was being performed by the nursing staff per policy.

The Surveyor asked if the process of transfer to the floor from another area was standardized, the Nurse Manager said I don't believe it was completed, not yet. The Surveyor asked if any changes to the system were implemented after the incident and the Nurse Manager said if there was a fix it would be addressed in the August (2018) meeting (over 132 days after the incident occurred) where we will develop a standard way for orders to be done.

Based on observations, record review and interviews, the Hospital failed to update medication administration policies to reflect the Hospital's change in practice with regard to using a scanner to document medication administration.

Findings include:

The Pediatric Intensive Care Unit (PICU) Progress Note, dated 3/22/18, indicated Patient #1 was admitted to the Pediatric Unit on 3/2/18. Patient #1 was scheduled for a surgical procedure on 3/21/18. Patient #1's medications were placed on hold prior to going to surgery and upon return to the floor Patient #1's medications were still on hold which included an order for Aspirin 40.5mg. The Note indicated the nurse caring for Patient #1 administered 405 mg of Aspirin (10 times the ordered dose) to Patient #1. The Progress Note indicated that Patient #1 required ICU level of care due to acute metabolic acidosis and was at risk for respiratory deterioration requiring intubation. Patient #1 required frequent assessments, non-invasive respiratory support and intravenous Sodium Bicarbonate.

The Nurse Manager of the Pediatric Unit was interviewed on 7/2/18 at 9:55 A.M. The Nurse Manager said that when medications are on hold they need to be reviewed by the physician and then reviewed and released from the hold by the nurse. The Nurse Manager said that Nurse #1 had some misunderstandings of the process to clear Patient #1's medication "Hold" and gave Patient #1 his/her medications. The Nurse Manager said that medications on "Hold" are not able to be scanned. If Nurse #1 had scanned the medications, the medication administration program would have alerted the nurse of the overdose. The Nurse Manager said that it is her expectation that the nurses use the scanner for all medication administrations with the exception of emergency situations.

As a response to this incident the Nurse Manager said that she sent an email to be printed and signed by all nursing staff on the unit. The Nurse Manager said that the email indicated that medications should be reviewed and reconciled by a provider (physician) and nursing should then release the Medication Administration Record after the review process has been completed. The email also indicated that nurses are to scan the patient bracelet barcode prior to elective medication administration.

Review of the Hospital's policy titled, 2030 Medication Administration, does not indicate that a scanner should be used at any time during medication administration nor does it mention a scanner anywhere in the three page document.

The Surveyor interviewed the Chief Quality Officer on 7/3/18, at 12:24 P.M. The Chief Quality Officer said that, after implementation of the scanner for medication administration, the Medication Administration Policies were not updated appropriately.