HospitalInspections.org

Based on finding from document review and interview, the hospital lacked a policy and procedure (P&P) that automatically stops medications (not specifically prescribed as to time or number of doses) after a reasonable amount of time as determined by the medical staff.

Findings include:

-- Per review of hospital P&P titled "Medication Stop/Renew Order," effective date 7/15/11, "Certain medications may be subject to automatic "stop" (discontinuance of medication) based on therapeutic use or legal requirements....Current automatic stops: Controlled Substances...others: As determined by P&T (Pharmacy and Therapeutics) committee." However, during interview with the Assistant Director of Pharmacy on 7/10/15 at 10:00 am and the Director of Pharmacy at 10:30 am, other than narcotics the hospital does not have any automatic stop orders.

Based on finding from document review and interview, the hospital's pharmacy did not review medication occurrence reports entered into MIDAS (computerized event management system). Additionally the hospital's policy and procedure (P&P) for Medication Occurrence reporting is inconsistent with staff practice.

Findings include:

-- Per interview with the Assistant Director of Pharmacy on 7/10/15 at 10:00 am and the Director of Pharmacy at 10:30 am, medication events (errors and near misses) are entered into MIDAS.

-- Per interview with the Director of Regulatory Affairs on 7/21/15 at 3:00 pm, once a medication related occurrence report is entered into MIDAS it appears on a pharmacist's work list for review. However, the pharmacist was not aware he/she needed to review the work list. At the time of this survey there were 75 medication occurrences on the work list waiting for the pharmacist to review.

-- During interview with the Director of Pharmacy and Assistant Director of Pharmacy on 7/21/15 at 3:30 pm, they acknowledged that medication related occurrence reports entered in MIDAS were not being reviewed by Pharmacy staff.

-- Per review of the hospital P&P titled "Medication Occurrence Reporting," effective date 1/1/10, it directed staff to document medication occurrences on Form SSF260.

-- However, per interview with Director of Pharmacy and Assistant Director of Pharmacy on 7/21/15 at 3:40 pm, medication occurrences are entered into MIDAS. They acknowledged the P&P is not up to date.

During interview with the Director of Regulatory Affairs on 7/10/15 at 3:30 pm, and on 7/21/15 at 3:00 pm, the above findings were acknowledged.