HospitalInspections.org

Based on record review and interview, the facility failed to provide 1 of 1 ( #1) patients care in a safe setting. Findings include:

During review of the medical record for patient #1 with the Director of Quality Management (DQM) on 12/15/2010, it was noted that the patient received a cat scan with both oral and intravenous contrast. The order placed into an electronic ordering system by the emergency department physician was for " CT Abdomen + Pelvis W/ Contrast and a comment placed into the comment section that read "Oral contrast only." Per the DQM this was how the physician was trained to put the order into the system. She also stated that the CT tech did not see the comment section when she pulled the order up onto the computer screen in the radiology department because you had to scroll over on the screen to see the comment section. Interview with Staff J (Pharmacy) revealed that they get a faxed sheet sent to them from the radiology department with the contrast order on it. The faxed document reviewed did not contain a physician's signature because it was done electronically. The tech thus ordered the intravenous contrast per radiology standing orders based on the assessment information she had received form the patient prior to the exam. The pharmacist then dispensed the contrast for the patient based on the faxed document and did not look at the physicians order in the system which read "oral contrast only."