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UPMC PASSAVANT
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on a review of facility policy and medical record (MR) and staff interview (EMP), it was determined that the facility failed to ensure that medications were prepared and administered in accordance with Federal and State laws, and the order of the practitioner or practitioners responsible for the patient's care for one of one intravenous medical record reviewed (MR1).
Findings include:
Review of facility policy on September 28, 2017, at approximately 2:40 PM revealed, " ... Medication Administration Date: May 2017 Medications are administered per the order of licensed independent practitioners with clinical privileges granted in accordance with Medical Staff By Laws or Rules and Regulations. Licensed staff may administer medications in accordance with hospital policy, procedure pertinent State laws and Practice Acts and governmental rules and regulations. ... Medication Includes any prescription medications; sample medications; herbal remedies; vitamins; ... intravenous solutions (plain, with electrolytes and/or drugs) ..."
1. Review of MR1 on September 28, 2017, at approximately 2:00 PM revealed an order for a continuous intravenous (IV) infusion of D5 1/2 (5% Dextrose in 1/2) NS [Normal Saline] 1,000 ml [milliliters] at the rate of 100 ml's per hour to start on April 21, 2017, at 14:40. The fluid was infused at 100 ml's per hour until May 9, 2017, at 11 PM. On May 9, 2017, from 11:00 PM through 6:00 AM it was documented that the fluid was infused at 150 ml/hour. There was no order to reflect the infusion rate of 150 ml/hour.
2. Continued review of MR1 revealed an order which was written on May 2, 2017, for a continuous IV infusion of NS 1,000 ml's bag to be administered at the rate of 40 ml's per hour over 25 hours. The fluid was infused at 40 ml's an hour until May 10, 2017, at 7 PM. On May 10, 2017, at 7:00 PM through May 11, 2017, at 1:00 PM, it was documented that the fluid was infused at the rate of 70 ml/hr. There was no order to reflect the infusion rate of 70 ml/hour.
On September 28, 2017, at approximately 2:30 PM when clarification was requested for the incorrect infusion rate, EMP1 stated, "I don't know maybe it was a typo."