HospitalInspections.org

Based on documentation review, it was determined the Hospital had not (yet) fully implemented the Corrective Action Plan associated with its Internal Investigation for one of one SRE/medication error/serious injury.

Findings included:

Review of the Corrective Action Plan associated with the Hospital Internal Investigation of the 4/20/15 medication incident, related to a high rate infusion of Levophenthe via an IV infusion pump, reviewed by the Surveyor on 6/9/15, revealed the following:

1) Nursing staff did not use the restore function option available when identifying an issue with the pumps, the nursing staff were reprogramming the pumps therefor increased the risk for error.

2) The Hospital's medication policies and procedures related to High Risk Alert Medication did not require an auxiliary label (intravenous line) or a check by 2 registered nurses for the administration of Levophed.

3) The Hospital's medication policies and procedures related to continuous IV infusion did not include mandatory line tracing from pump to channel to fluid source prior to all pump infusions when multiple lines were in use.

The Corrective Action Plan associated with the Hospital Internal Investigation regarding the IV infusion medication error that occurred on 4/10/15 indicated the following changes:

1) Hospital wide nursing re-education regarding utilization of evidence based benefits of using restore function in medication error reduction to be completed by 7/10/15.

2) A revision to the High Risk Medication policy/procedure indicated that by 6/30/15:

a) All high risk medications will require tubing label which include the drug name and
b) When multiple intravenous lines are used mandatory tracing of intravenous tubing will be performed from the pump channels to the fluid source prior to all pump infusions.


The Corrective Action Plan indicated that the implementation date for completion for all changes was 7/10/15.