HospitalInspections.org

Based on interview, medical record review and policy review, the hospital failed to:
- Ensure staff verified medications prior to administration for all patients cared for in the Emergency Department (ED).
- Perform a two-nurse verification for high alert medications for two (#10 and #16) of seven records reviewed.
- Prevent a medication error when one patient (#24) was given the wrong medication dose of 24 medical records reviewed.
- These failures placed all patients at risk for medication errors.

The hospital census was five.

This failed practice resulted in a system failure and noncompliance with 42 CFR 485.635 Condition of Participation (CoP): Provision of Services.

The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ).

As of 08/07/24, the hospital provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming staff on medication administration verification. All remaining staff were to complete education prior to the start of their next shift.

Based on interview, medical record review and policy review, the hospital failed to:
- Ensure staff verified medications prior to administration for all patients cared for in the Emergency Department (ED).
- Perform a two-nurse verification for high alert medications for two (#10 and #16) of seven records reviewed.
- Prevent a medication error when one patient (#24) was given the wrong medication dose of 24 medical records reviewed.
- These failures placed all patients at risk for medication errors.

Findings included:

Review of the hospital's policy titled, "High Alert Medications," revised 04/2024, showed:
- High alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. The purpose of this policy is to identify said high-alert medications and provide instructions for use to minimize risk of adverse events.
- All high alert medications should undergo a double nurse verification of the medication and dose before administration whenever possible.
- Lovenox (a medication used to help prevent the formation of blood clots [clumps that occur when blood hardens from a liquid to a solid]) treatment doses will have a second nurse verification on the electronic medical record (EMR).
- Tenecteplase (TNK, medication to treat blood clot) is a high alert medication and the ordering, dispensing and administration is delineated in a separate policy.

Review of the hospital's policy titled, "Stroke Policy and Process," revised 03/2024, showed:
- If TNK is to be given the Stroke Team will assist in the administration of TNK per protocol.
- Stroke dosing for TNK is 0.25 milligrams (mg) per kilogram (kg).
- The TNK dose was not to exceed 25 mg.
- The dose for a weight of 98 kg was 24.5mg.

Review of the hospital's policy titled, "Automated Dispensing Machines," reviewed 12/2023, showed:
- Override is a process of bypassing pharmacist review of the medication order to obtain a medication when assessment of the patient indicates that a delay in medication administration would harm the patient.
- Overrides are restricted to urgently needed medications.
- The override removal of medication from an automated dispensing machine should be limited at all costs.
- Pharmacy reviews the overrides each day to ensure orders exist, trends are noted, and brought forward.

Review of the hospital's document titled, "Occurrence Report Summary," dated 04/16/24, showed:
- Patient #24 was given a heart attack dose of TNK instead of a stroke dose.
- This was an error and could have necessitated monitoring and/or intervention to preclude harm.
- The patient received the heart attack dose of 50 mg of TNK instead of the stroke dose of 24.5 mg. The maximum dose for a heart attack is 50mg and the maximum dose for a stroke is 25 mg.
- TNK was administered before the ED provider entered the order into the EMR.
- TNK was administered without a pharmacist, provider or second nurse verification.

Review of Patient #24's medical record dated 04/16/24, showed:
- At 11:55 AM, she was a 68-year-old female who presented to the ED with a complaint of chest pain. The left side of her face was tingling. Her cardiologist (a physician who is an expert in the care of your heart and blood vessels) recommended she go to the ED for a complaint of "head pain."
- Her weight was 98 kilograms.
- At 1:10 PM, a Code Stroke was activated.
- At 1:56 PM, a note showed the ED provider spoke with cardiology and the patient again and found out she was experiencing left sided weakness and left facial "tingling."
- At 2:04 PM, a verbal order was placed to administer TNK 50 milligrams IV (in the vein).
- At 2:05 PM, TNK 50mg was given IV. There was no two-nurse medication verification documented.
- At 2:21 PM, she had left sided weakness.

Review of Patient #16's medical record dated 07/27/24 through 07/29/24, showed:
- On 07/28/24 at 12:14 PM, Lovenox was given.
- On 07/29/24 at 9:34 AM, Lovenox was given.
- There were no second nurse medication verifications completed for either Lovenox administration.

Review of Patient #10's medical record dated, 08/07/24 showed at 9:38 AM, Lovenox was given. There was no second nurse medication verification completed.

During an interview on 08/07/24 at 10:54 AM and 12:20 PM, Staff S, Chief Nursing Officer (CNO), stated that she agreed patients were at risk of harm without a medication verification process in place. Scanning medication in the ED created a billing discrepancy. Patients were charged twice because they were charged when the order was written and again when the medication was scanned. She agreed patient safety was a priority to patient billing. The previous on-site pharmacist requested the ED nurses did not scan the medication because they walked the medications to the nurse to verify the correct medication and dose was administered. The current EMR system did not communicate with the medication dispensing machine. Every medication administered in the ED was retrieved via override. The previous on-site pharmacists reviewed the medication dispensing machine reports printed after medications were administered and compared them to the physician orders to ensure the correct medications and doses were administered. She agreed it was not the best practice to review medication administration for errors after the medication was administered. When the hospital transitioned to the virtual pharmacists on 07/30//24 she became responsible for reviewing the medication dispensing machine reports and comparing them to the patient orders to ensure accurate medication and dose administration. She did not have time to review the reports.

During an interview on 08/06/24 at 2:30 PM and 08/07/24 at 1:15 PM, Staff F, ED Manager, stated that she agreed patients were at risk of harm without a medication verification process. The EMR did not communicate with the medication dispensing machine and the ED nurses did not scan medications prior to medication administration. She believed medication documentation could not be completed for high alert medications without a second nurse verification. She expected a second nurse verification was completed for high alert medications as indicated by the policy. The pharmacy never communicated any medication errors to her. The wrong dose of TPK was given to Patient #24. The heart attack dose was given instead of the stroke dose. The nurse who made the error was an agency nurse and she was not familiar with the medication. She had never administered TPK.