HospitalInspections.org

Based on observation, document review, clinical record review, and staff interview the hospital failed to meet the regulatory requirements for the Condition of Participation: CFR 485.635 Provision of Services as evidenced by the following:

1. The hospital failed to ensure implementation of policy and procedures for safe and effective systems for administration of drugs when:

a. License nurses did not scan (a scanner which scan the patient's wrist band and the medication to ensure the right patient, right medication, and right dose) patient identification and medication prior to medication administration for two of five sampled patients (Patient 4 and Patient 1). (Refer to C-1006)

b. Registered Nurse (RN) 1 used a premixed IV (a way to administer medication into a vein) bag of Vancomycin (a bacterial antibiotic used against resistant strains of bacteria) 1500 mg (milligram- unit of measure) dose for one of four sampled Patient (Patient 1), who had a Physician's order for a non- premixed Vancomycin 1250 mg. (Refer to C-1006)

2. The hospital failed to follow its Policy and Procedure (P&P), titled, "Pharmacy and Therapeutics Committee", when one of one Pharmacy and Therapeutics Committee (P&T- committee that formulates policies regarding evaluation, selection, diagnostic and therapeutic use, and monitoring of medications and medication-associated products and devices) meeting minutes did not include at least one or more physician assistant, and/or nurse practitioner (non-physician practitioners) to serve on the advisory group responsible for developing hospital policies, reviewed and approved the hospital Policy and Procedures (P&Ps) titled, "Medication Administration Using Barcode System" dated 5/2/23 and "Drug Room Medication Procurement, Storage, Distribution and Dispensing", dated 5/2/23. (Refer to C-1008)

3. The hospital failed to administer pharmaceutical services (are activities of pharmacist in the healthcare system to provide access to high quality medications, including preparation and dispensing) in accordance with its policy and procedures when:

a. Licensed Vocational Nurse (LVN) 1 accessed, removed, and administered hydrocodone/acetaminophen (a medication used to treat moderate and severe pain) for one of one sampled patient (Patient 1) from the hospital's drug storage supply. (Refer to C-1016)

b. Registered Nurse (RN) 1 left two diltiazem (a medication that treats high blood pressure and chest pain) pills for one of three sampled patients (Patient 3) unattended. (Refer to C-1016)

4. The hospital failed to ensure the implementation of procedures for reporting adverse drug reactions and errors for one of four patients (Patient 2) when a medication error was not reported. (Refer to C-1018)

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision for safe and appropriate use of medications to meet the needs of the patients and to minimize adverse medication outcomes.

Based on observation, interview and record review, the hospital failed to ensure implementation of policy and procedures for safe and effective systems for administration of drugs when:

1. License nurses did not scan patient identification and medication prior to medication administration for two of five sampled patient (Patient 4 and Patient 1).

2. Registered Nurse (RN) 1 used a premixed intravenous (IV- a way to administer medications into a vein) bag of Vancomycin (a bacterial antibiotic used against resistant strains of bacteria) 1500 mg (milligram- unit of measure) dose for one of four sampled patient (Patient 1), who had a physician's order for a non- premixed Vancomycin 1250 mg IV.

These failures had the potential for Patient 1 and Patient 4 to receive the wrong medications and wrong dose which could result to adverse medication reactions (undesired effect of a drug) including death.

Findings:

1a. During a concurrent interview and record review on 6/6/23 at 2:57 p.m. with Registered Nurse Pharmacy Coordinator (RNPC), Patient 4's oxycodone-acetaminophen (pain medication) 5 mg/325 mg (milligrams -unit of measurement) medication ordered 5/28/23 at 11:24 a.m. was reviewed. Patient 4's oxycodone-acetaminophen order indicated, "5/29/2023 15:58 [3:58 p.m.] given 1 tab oral ... med verify= N [no (not scanned)], 6/2/2023 22:59 10:59 p.m.] given 1 tab oral ... med verify=N, 6/3/2023 21:37 [11:37 p.m.] given 1 tab oral ... med verify= N, 6/4/2023 3:35 a.m. given 1 tab oral ... med verify =N " The RNPC stated, license nurse did not follow the hospital's barcode scanning procedures prior to medication administration.

During an interview on 6/7/23 at 3:37 p.m., with Pharmacist Consultant (PC), the PC stated, nursing staff did not follow the hospital's policy and procedure for using barcode scanning prior to medication administration. PC stated, "very important, its safety not to prevent medication error ... potential for wrong medication, wrong patient and wrong dose".

During an interview on 6/8/23 at 1:48 p.m., with Director of Patient Care Services (DPCS), the DPCS stated, nursing staff was expected to scan every medication and every patient arm band every time prior to medication administration for patient safety, catching near misses (an incident which did not reach the patient by chance or timely intervention) and preventing medication errors.








45938

1b. During a concurrent interview and record review, on 6/7/23, at 11:34 p.m., with Licensed Vocational Nurse (LVN) 1, Patient 1's "Medication Administration" (MA), dated 6/2/23 was reviewed. The "MA" indicated Patient 1 was administered clonidine (a medication used to treat high blood pressure) at 3:23 p.m. The "MA" indicated, " ... Patient Armband Not Scanned ..." LVN 1 stated, Patient 1 was administered clonidine without having his armband scanned. The "MA" indicated, Patient 1 was administered aspirin (a medication used to treat mild and moderate pain) at 9:19 a.m. The "MA" indicated, " ...Medication Not Scanned ..." LVN 1 stated, Patient 1 was administered aspirin without the medication being scanned. The "MA" indicated, Patient 1 was administered atorvastatin (a medication used to slow down the production of cholesterol in the body) at 11:46 p.m. The "MA" indicated, " ... Medication Not Scanned ..." LVN 1 stated, Patient 1 was administered atorvastatin without the medication being scanned. Patient 1's "MA", dated 6/3/23 was reviewed. The "MA" indicated, Patient 1 was administered clonidine at 8:53 a.m., 2:49 p.m. and 8:55 p.m. The "MA" indicated " ...Patient Armband Not Scanned ..." on all three doses. LVN 1 stated, Patient 1 was administered clonidine without having his armband scanned. The "MA" indicated, Patient 1 was administered aspirin at 8:53 a.m. The "MA" indicated, " ...Patient Armband Not Scanned ..." LVN 1 stated, Patient 1 was administered aspirin without the medication being scanned. The "MA" indicated, Patient 1 was administered atorvastatin at 9:03 p.m. The "MA" indicated, " ... Medication Not Scanned ..." LVN 1 stated, Patient 1 was administered atorvastatin without the medication being scanned. Patient 1's "MA" dated 5/31/23 was reviewed. The "MA" indicated, Patient 1 was administered vancomycin at 9:00 p.m. The "MA" indicated, " ... Patient Armband Not Scanned ..." LVN 1 stated, Patient 1 was administered vancomycin without his armband being scanned. LVN 1 stated, the practice at the facility was to scan the patient's armband and scan the medication prior to administering the medication. LVN 1 stated, it was important to scan the patient's armband and medication to ensure you do not give the wrong medication to the patient.

During an interview on 6/7/23 at 1:46 p.m., with the RNPC, the RNPC stated, the practice at the facility was to scan the patient's armband and scan the medication. The RNPC stated license nurse not scanning the patient's armband and scanning the medication was going against the hospital's policy and procedure. The RNPC stated, it was important to scan the patient's armband and scan the medication to ensure the five medication rights (the right patient, the right drug, the right time, the right dose, the right route) was followed, and prevent medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer) to ensure patients safety.

During an interview on 6/7/23, at 1:59 p.m., with the PC, the PC stated, the practice at the facility was to scan the patient's armband and scan the medication prior to administering medications. The PC stated, it was important to scan the patient's armband and scan the medication to prevent medication errors and ensure patient safety.

During an interview on 6/8/23 at 1:48 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated, the expectation was for the license nurse to scan patient's armband and medication prior to medication administration.
The DPCS stated, it was important to scan patient's armband and medication every time to catch near misses and medication errors. The DPCS stated, scanning armbands and medication ensured all patient safety measures were taken for safe medication administration.

During a review of the hospital's policy and procedure (P&P) titled, "Medication Administration Using Barcode System", dated 5/2/23, the P&P indicated, " ...The nurse shall enter the patient's room with the medication to be administered, the MAR [Medication Administration Record] and the barcode reader. The nurse shall: Verify the label on the medication with the patient's MAR before scanning Identify the patient using two (2) patient identifiers ... Scan the following using the handheld barcode reader: The barcode on the patient's identification wristband before medication administration ... The barcode on the medication immediately before administration to verify: The right patient The Right medication, The Right time The Right dose The Right route... The Barcode system shall give the nurse a visual warning if the medication cannot be matched with the order ..."

2. During a concurrent observation and interview, on 6/6/23, at 2:49 p.m., with RN 1, in Patient 1's room, a bag of Vancomycin 1500 mg in 300 ml (milliliters) hung on the IV pole ( a device used to keep IV bags in placed) had clear fluid remaining in the bag. The Vancomycin 1500 mg IV bag had a label indicated, " ... [Patient 1] ... ORDER: ... Vancomycin 1250 mg / 250 ml IV ... 8:38 [RN 1's initials] 6/6/23 ..." RN 1 stated, Patient 1's medication physician order was for Vancomycin 1250 mg IV. RN 1 stated, she used the Vancomycin 1500 mg premixed IV bag because there were no premixed bags for Vancomycin 1250 mg IV available. RN 1 stated she used a premixed bag of Vancomycin 1500 mg and programmed the IV pump machine (a medical device that delivers medication fluids, into a patient's body in controlled amounts) to infused only 1250 mg out of the 1500 mg Vancomycin IV bag. RN 1 stated, this was an acceptable practice at the facility when the ordered dose was not available in a premixed bag.

During a review of Patient 1's "RECORD OF ADMISSION", [undated], the "RECORD OF ADMISSION" indicated, Patient 1 was admitted on 5/31/23 for Osteomyelitis (bone infection) of the right foot.

During a review of Patient 1's "Order Chronology" dated 6/8/23, the "Order Chronology" indicated, Patient 1 had a physician order for " ... Vancomycin 1250 mg ... 250ml IV ...". The "Order Chronology" did not indicate the doctor ordered a premix bag of Vancomycin.

During a review of Patient 1's "Medication Record", dated 6/8/23, the "Medication Record" indicated, RN 1 administered Vancomycin 1250 mg to Patient 1 on 6/6/23, at 8:38 a.m. by RN 1.

During an interview on 6/7/23, at 1:46 p.m., with the RNPC, the RNPC stated, the hospital does not supply Vancomycin 1250 mg in premixed bag. The RNCP stated, to have a Vancomycin 1250 mg dose, the Vancomycin dose should have been mixed by RN 1. The RNCP stated, RN 1 should have not used the Vancomycin 1500 mg premixed bag. The RNCP stated, to use a Vancomycin premixed bag, it should be indicated in the physician's order. The RNCP stated Patient 1's Vancomycin order did not indicate to use a premixed medication bag. The RNPC stated, using a premixed vancomycin medication without physician order was not the standards of practice. The RNCP stated, it was important to follow the physician order to prevent medication errors and protect the patients.

During an interview on 6/7/23, at 1:59 p.m., with the PC, the PC stated, the hospital does not supply Vancomycin 1250 mg in premixed IV bag. The PC stated RN 1 should have not used the Vancomycin 1500 mg premixed bag. The PC stated, to use the Vancomycin premixed bag for Patient 1 required a physician's order. The PC stated, Patient 1's Vancomycin physician's order did not indicate to used Vancomycin premixed bag. The PC stated, using a premixed medication IV bag without a physician's order was a medication error. The PC stated, it was important to follow the physicians order to prevent medication errors.

During a review of the facility's P&P titled, "Sterile Admixing Performed by Nursing", dated 8/11/22, the P&P indicated, " ... All intravenous (IV) medication administrations shall follow the guidelines set forth in policy ... Whenever possible, premixed or closed system drug delivery system will be utilized. Should medication in these forms not be available, an RN shall perform the IV admixture ..."

Based on interview and record review, the hospital failed to follow its Policy and Procedure (P&P), titled, "Pharmacy and Therapeutics Committee", when one of one Pharmacy and Therapeutics Committee (P&T- committee that formulates policies regarding evaluation, selection, diagnostic and therapeutic use, and monitoring of medications and medication-associated products and devices) meeting minutes did not include at least one or more physician assistant, and/or nurse practitioner (non-physician practitioners) to serve on the advisory group responsible for developing hospital policies, reviewed and approved the hospital Policy and Procedures (P&Ps) titled, "Medication Administration Using Barcode System" dated 5/2/23 and "Drug Room Medication Procurement, Storage, Distribution and Dispensing", dated 5/2/23.

This failure resulted in the implementation of hospital P&P for medication storage, dispensing and administration without the input from the hospital's mid-level practitioners which placed patient at risk for medication errors.

Findings:

During an interview on 6/7/23 at 1:38 p.m., with Pharmacy Consultant (PC), the hospital's "Pharmacy and Therapeutics Minutes", dated 5/3/23, hospital's P&Ps titled, "Medication Administration Using Barcode System" dated 5/2/23 and "Drug Room Medication Procurement, Storage, Distribution and Dispensing", dated 5/2/23 were reviewed. The PC stated, the P&Ps were reviewed and approved by the P&T committee on 5/3/23, which comprised of a pharmacist, registered nurses, chief nursing officer, and physician. The PC stated, the P&T committee did not include non-physician practitioners.

During an interview on 6/7/23 at 3:38 p.m. with PC, the PC stated, he attended the P&T committee meetings and acknowledged the P&T committee did not consist of a physician assistant, and/or nurse practitioner. The PC stated it was important to include a physician assistant and/or nurse practitioner on the P&T committee since they are providing care to patients in the hospital. The PC stated, medication administration using a barcode system (a scanner which scan the patient's wrist band and the medication to ensure the right patient, right medication, and right dose) was important to prevent medication error.

During an interview on 6/8/23 at 9:49 a.m., with Medical Doctor (MD) 1, MD 1 stated, the hospital staff included a nurse practitioner and a physician assistant. MD 1 stated, the P&T committee did not consist of non-physician practitioners to help develop and review hospital's P&P, and a physician assistant and/or nurse practitioner should have been included on the P&T committee if they were on the hospital's staff.

During an interview on 6/8/23 at 1:51 p.m., with Director of Patient Care Services (DPCS), DPCS stated, it was important to have a multi-disciplinary team included mid-level practitioners on the hospital's P&T committee. The DPCS stated, "Anyone prescribing medications should be on there."

During a review of the hospital's P&P, titled, "Pharmacy and Therapeutics Committee", dated 5/5/21, the hospital's P&P indicated, " ...this committee has been comprised of the physician chairperson; hospital consulting pharmacist; nurse manager for Acute, Emergency Department (ED), Clinics, Home Health, and Skilled Nursing Facility (SNF), CNO [chief nursing officer], a representative from administration, Quality Improvement Officer and Infection Preventionist ... This committee shall recommend and approve policies and procedures (P&P) relating to the procurement, storage, and quality of drugs, chemicals, and biologicals obtained by the [hospital]."hospital]."

Based on interview and record review, the hospital failed to administer pharmaceutical services in accordance with its policy and procedures when:

1. Licensed Vocational Nurse (LVN) 1 accessed, removed, and administered hydrocodone/acetaminophen (a medication used to treat moderate and severe pain) for one of one sampled patient (Patient 1) from the hospital's drug storage supply.

2. Registered Nurse (RN) 1 left two diltiazem (a medication that treats high blood pressure and chest pain) pills for one of three sampled patients (Patient 3) unattended.

These failures had the potential for Patient 1 and Patient 4 to receive the wrong medications and wrong dose which could result to adverse medication reactions (undesired effect of a drug) including death.

Findings:

1. During a concurrent interview and record review on 6/7/23 at 1:15 p.m. with LVN 1, the "Medication Cart Narcotic Drug Log " was reviewed. LVN 1 stated, she had access to the medication cart narcotic drug supply. LVN 1 stated, she obtained the hydrocodone/acetaminophen 10 milligrams (mg- unit of measure)/325 mg tablets from the narcotic medication cart and administered to Patient 1.

During a review of the "Medication Cart Narcotic Drug Log" dated 6/6/23-6/7/23, the log indicated LVN 1 had obtained one hydrocodone/acetaminophen 10 mg/325 mg tablet on 6/7/23 at 8:11 a.m., and another tablet on 6/7/23 at 12:19 p.m. for Patient 1.

During a review of Patient 1's "Medication Administration Record (MAR)", undated, the MAR indicated LVN 1 administered one hydrocodone/acetaminophen 10 mg/325 mg tablet on 6/7/23 at 8:21 a.m., and another tablet on 6/7/23 12:22 p.m. to Patient 1.

During an interview on 6/7/23 at 1:25 p.m. with Registered Nurse Pharmacy Coordinator (RNPC), the RNPC stated, all nurses including licensed vocational nurses, had access to the narcotics supply stored in the medication cart.

During a concurrent interview and record review on 6/7/23 at 3:41 p.m., with the Pharmacist Consultant (PC), the hospital's P&P titled, "Access to Drug Storage Area", dated 7/16/19, was reviewed. The PC stated, nursing staff did not follow the hospital's P&P which indicated, "Registered Nurses and pharmacy personnel are the only personnel authorized to have access to the drug storage areas for the purpose of removing medications."

During an interview on 6/8/23 at 1:55 p.m., with Director of Patient Care Services (DPCS), the DPCS stated, it was important for nursing staff to follow the hospital's P&P to ensure nursing staff was practicing within their scope and adhering to the law.


45938

2. During a concurrent observation and interview on 6/6/23, at 2:49 p.m., with RN 1, outside Patient 3's room, RN 1 placed a medicine cup containing 2 diltiazem pills on top of the computer on wheels then walked away from the medication, down the hallway, towards the nurses station. RN 1 stated, it was not the practice in the hospital to leave medications unattended. RN 1 stated, it was important not leave medications unattended to prevent medication errors and for someone to take the medications.

During a review of Patient 3's "RECORD OF ADMISSION", [undated], the "RECORD OF ADMISSION" indicated, Patient 3 was admitted to the hospital on 5/30/23 for Deconditioning (the reversal of previous conditioning of a behavior), Altered Mental State (change in mental function).

During a review of Patient 3's "Order Chronology", dated 6/8/23, the "Order Chronology" indicated Patient 3 had an order for " ... Start Date ... 06/06/23 ... diltiazem 60 MG [milligrams] ..."

During an interview on 6/8/23, at 1:45 p.m. with the RNPC, the RNPC stated, the practice in the hospital was for medications to be always in the nurse's view prior to administration. The RNPC stated, RN 1 did not follow the hospital's policy for leaving the diltiazem medications unattended. The RNPC stated, it was important not to leave medication unattended to prevent medication errors.

During an interview on 6/8/23, at 1:50 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated, medications should not be left unattended and should be always in the nurse's possession. The DPCS stated, leaving medications unattended was an unsafe practice (any action or lack of action that is contrary to generally accepted standards).

During a review of the hospital's policy and procedure (P&P), titled "MEDICATION SECURITY", [undated], the P&P indicated, " ... POLICY: All drugs and biologicals stored in this hospital shall be kept in a secure area, locked when appropriate and accessible only to authorized staff. A secure area is defined as an area that prevents unauthorized individuals unmonitored access to drugs and biologicals ..."

Based on interview and record review, the hospital failed to ensure the implementation of procedures for reporting adverse drug reactions and errors for one of four patients (Patient 2) when a medication error was not reported.

This failure resulted for medication errors not investigated and corrected which had the potential for Patient 2 to experienced medication adverse reactions (undesired effect of a drug) and for continued occurrence of unreported medication errors.

Findings:

During a review of Patient 2's "RECORD OF ADMISSION (is a part of the medical record that documents the patient history and physical, diagnosis, procedures)", [undated], the "RECORD OF ADMISSION" indicated, Patient 2 was admitted to the hospital on 6/3/23 for Pneumonia (a lung infection), and Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty or discomfort in breathing).

During a review of Patient 2's "Order Chronology (list of physician's order)", dated 6/8/23, the "Order Chronology" indicated, Patient 2 had a doctors order on 6/4/23 for cefepime (an antibiotic that can treat bacterial infections) 1 gram (unit of measure) IV (intravenous [administered into a vein]) every 8 hours.

During a concurrent interview and record review, on 6/7/23, at 10:21 a.m., with Registered Nurse (RN) 2, Patient 2's "Medication Record" [undated] was reviewed, the "Medication Record" indicated, Patient 2 was administered cefepime 1 gram on 6/4/23, at 7:10 a.m. and administered cefepime 1 gram on 6/4/23, at 9:29 a.m. RN 2 stated, the dose administered at 9:29 a.m. was administered too soon and should have been given 8 hours after the 7:10 a.m. dose.

During a concurrent interview and record review, on 6/7/23, at 1:26 p.m., with RN 2, Patient 2's "Medication Record" [undated] was reviewed, the "Medication Record" indicated, Patient 2 had a doctor's order for cefepime 1 gram to be given every 8 hours. RN 2 stated, Patient 2's 9:29 a.m. dose of cefepime was a medication error. RN 2 stated, Patient 2 should have received the next cefepime dose at 3:00 p.m. RN 2 stated, she was unable to find documentation of the medication error in Patient 2's clinical record. RN 2 stated, the medication error should have been reported through the hospitals electronic reporting system. RN 2 stated, it was important to report medication errors for patient safety, nurse education and to prevent further occurrences. RN 2 stated, Patient 2 could have experienced medication adverse reactions including death if medication errors are not reported.

During an interview on 6/7/23, at 1:46 p.m., with the Registered Nurse Pharmacy Coordinator (RNPC), the RNPC stated, all medication errors should be reported to the physician and reported in the hospitals reporting system. The RNPC stated, medication errors reported through the hospital electronic reporting system are sent to the Pharmacist Consultant (PC). The RNPC stated, Patient 2 had an order for cefepime to be administered every 8 hours, and it was administered on 6/4/23 at 7:10 a.m. with next dose administered at 9:29 a.m. The RNCP stated, the cefepime administered at 9:29 a.m. was a medication error.

During an interview on 6/7/23, at 1:59 p.m., with the PC, the PC stated, Patient 2 received cefepime on 6/4/23 at 7:10 a.m. and received the next dose on 6/4/23 at 9:29 a.m. The PC stated, he did not know why Patient 2 received the 9:29 a.m. dose. The PC, stated the doctors order for cefepime was not followed and the administration at 9:29 a.m. was a medication error. The PC stated, he was unaware of the medication error. The PC stated, the medication error was not reported in hospitals electronic reporting system and needed to be reported. The PC stated, it was important to report medication errors to prevent them from happening again and to learn from the mistake. The PC stated, there was a potential for Patient 2 to experience gastrointestinal (stomach and intestines) side effects such as diarrhea.

During an interview on 6/8/23, at 1:50 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated, Patient 2's was administered cefepime on 6/4/23 at 7:10 a.m. and at 9:29 a.m. The DPCS stated, the cefepime dose at 9:29 a.m. was a medication error and should have been reported through the hospitals electronic reporting system. The DPCS stated, there was a potential for a patient's creatinine clearance (a test which provides information how well the kidneys are working) to be affected if given too much cefepime.

During a review of the hospital's policy and procedure (P&P) titled, "Medication Errors", dated 3/13/2019, the P&P indicated, " ... Medication errors are documented and reported to the patient's attending physician, the patient, the Director of Nursing, and the Quality Director. In addition to reporting actual errors, all potential errors (near misses) should be reported as well ... Medication Error ... Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer ... This includes transcription error, omission, duplication, or any error related to the "five rights [the right patient, the right drug, the right time, the right dose and the right route]" of drug administration ... The following information is documented in the patient's medical record: a) Factual description of the error. b) Name of the physician and time notified. c) Physician's subsequent orders. D) Patient's condition for 24 to 72 hours or as directed ... An incident report, Quality Review Report (QRR), is completed ..."

During a review of the hospital's P&P, titled, "Adverse Drug Event/Reaction and Medication Errors", dated 3/13/2019, the P&P indicated, " ... All potential and actual drug events, reactions and errors shall be reported by the healthcare professional(s) involved in, witnessing, or first discovering the event ... Upon discovery of an actual or potential event, an Occurrence Report shall be filled out electronically ... The person completing the Occurrence Report will select the Pharmacy as the secondary unit to ensure that the Pharmacist is informed. The physician shall be notified of all actual events/error as soon as they are discovered ..."