HospitalInspections.org

Based on interviews and documentation review, it was determined the Hospital had not (yet) completed its Internal Investigation related to the 4/24/10 ordering (and subsequent administration) of Haldol outside of parameters previously specified for Patient #1 by his/her Attending Physician.

Findings included:

Medical record documentation indicated oral Haldol ordered for Patient #1 on 4/24/10 was not ordered in compliance with parameters previously specified by his/her Attending Physician.

A review of medication-related Hospital Incident Reports completed during 2010 revealed Staff RN #1 completed a Report related to the 4/24-4/25/10 administration of Haldol to Patient #1 on 4/25/10. The Report indicated a physician covering for the Attending Physician (Covering Physician #3) became aware of the Haldol order and administrations at 10:00 AM and Patient #1's Daughter was notified at 10:30 AM.

Documentation indicated the (computerized) Incident Report regarding Patient #1's 4/24-4/25/10 Haldol administrations was routed to several management, patient safety and quality staff and a Preliminary Hospital Internal Investigation was underway. Thus far, the Investigation had determined: the Attending Physician's intent to limit the amount of Haldol administered to Patient #1 was not well communicated/flagged to other medical and/or the nursing staff; the Attending Physician's intent to limit the amount of Haldol administered to Patient #1 was not communicated to Pharmacy staff; Patient #1's reaction to Haldol was really an intolerance, not an allergy, and; the Hospital's computerized Order Entry system does not have a mechanism for communication of patient-specific limitations on future potential medication orders.

A review of the Hospital Internal Investigation process revealed Patient #1's 4/24-4/25/10 Haldol administrations and the associated Preliminary Hospital Internal Investigation was scheduled to be discussed at a (regularly scheduled) Patient Advocate/Patient Safety Specialist Meeting on Friday, 4/30/10, and at a (regularly scheduled) Patient Safety Committee on Monday, 5/3/10.

Based on interviews and documentation review, it was determined the Hospital had not (yet) developed and implemented a Corrective Action Plan related to the 4/24/10 ordering (and subsequent administration) of Haldol outside of parameters previously specified for Patient #1 by his/her Attending Physician.

Findings included:

Please see Tag A 287 for information related to the Hospital Internal Investigation regarding the 4/24/10 ordering (and subsequent administration) of Haldol outside of parameters previously specified for Patient #1 by his/her Attending Physician.

Because the Hospital Internal Investigation was not (yet) complete, a Corrective Action Plan had not (yet) been developed and implemented.