HospitalInspections.org

Based on record review the hospital failed to prepare and administer drugs and biological's in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under 482.12(c), and accepted standards of practice.

Findings include:

Hospital policies and procedures for the preparation and administration of all drugs and
biological's must not only comply with all applicable Federal and State laws, but also
must be consistent with accepted standards of practice based on guidelines or
recommendations issued by nationally recognized organizations with expertise in
medication preparation and administration. Examples of such organizations include, but
are not limited to:
o American Society of Health-System Pharmacists
(http://www.ashp.org/default.aspx)
o Infusion Nurses Society (http://www.ins1.org)
o Institute for Safe Medication Practices (www.ismp.org)
o National Coordinating Council for Medication Error Reporting and Prevention
(www.nccmerp.org)
o U.S Pharmacopeia (www.usp.org)

One of the nationally accepted standards are set by the National Coordinating Council for Medication Error Reporting and Prevention and requires orders to include indication for use.

Findings include:

Review of 7 (seven) medical records of patient that received a drug order by the physician as a onetime only, revealed, the physician's order did not include indication for the use of the onetime use drug.