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Based on policy review, observation and interview, the nursing staff failed to wipe the rubber stopper with alcohol prior to drawing up medication into a syringe for 2 of 2 observations (RN [Registered Nurse] #1, RN #2)

The findings included:

Review on 03/10/2016 of the facility policy "DRAWING UP MEDICATION FOR INJECTION" from Lippincott Procedures (no documented date), revealed " For single-dose or multidose vials:..Wipe the stopper of the medication vial with an alcohol pad and then draw up the prescribed amount of medication..."

Observation on 03/09/2016 at 1010 in the pre-op holding area revealed RN #1 drew up 3 single dose vials of medication (Decadron [anit-inflammitory medication], Versed [induces drowsiness and relieves anxiety medication], and Toradol [anti-infalammitory/pain medicaton]). Observation revealed the RN popped off the top (lid) of the medication vials and drew up each medication using a different syringe and needle. Observation revealed the RN failed to wipe the rubber stoppers with alcohol prior to drawing up the medication.

Observation on 03/10/2016 at 1440 on the first floor (medical floor) revealed RN #2 drew up heparin from a single-dose vial. Observation revealed the RN popped off the top (lid) of the heparin vial and drew up the medication into a syringe. Observation revealed the RN failed to wipe the rubber stopper with alcohol prior to drawing up the medication.

Interview on 03/10/2015 at 1240 with the hospital's CNO (Chief Nursing Officer) revealed the nursing staff should have wiped the rubber stoppers on the single-use medication devices prior to inserting the need to draw up the medication per facility policy. The interview confirmed the observational finding.