HospitalInspections.org

Based on policy review, record review and staff interview it has been determined that the hospital failed to administer medications in accordance with hospital policy for 1 of 4 patient's reviewed for subcutaneous heparin administration, Patient ID #1.

Findings are as follows:

A report submitted to the RI Department of Health on 11/16/2023 by the hospital's Risk Manager revealed that on 11/13/2023, a patient was administered, 100 units of insulin in error, after the nurse selected the insulin vial instead of the heparin vial. The patient required additional interventions including Glucagon, Dextrose 5%, 10% and 50%.

Review of the hospital's policy titled, "Medication Administration, System Admin 110" states in part,
...Five Rights of Medication Administration Practice
1. Right Patient
2. Right Medication: ensure that the medication being given matches what has been prescribed ...
3. Right Dose: Ensure that the dosage of the medication matches ...
4. Right Route
5. Right Time

According to the Lippincott procedure "Medication Administration and Monitoring Checklist, published in January 2007, the five rights of medication administration include verifying, prior to medication administration, that the right patient is being administered the right medication at the right dose, at the right time and by the right route.

Review of Patient ID #1's medical record revealed that the patient was admitted to the hospital on 11/12/2023 with extreme weakness, facial droop, and aphasia. Past medical history includes but is not limited to diabetes, and hypertension.

Review of a Significant Event Note dated 11/13/2023 at 5:35 PM revealed the following information: "notified by nursing that the patient received 1 ml subcutaneous insulin injection ... Endocrinology up to evaluate patient ... frequent glucose checks, and IV dextrose ordered ...

During a surveyor interview with Registered Nurse, Staff A on 11/20/2023 at 1:30 PM she explained to this surveyor that Patient ID #1 had been off the floor for several hours due to diagnostic testing on 11/13/2023. Upon their return she went into the patient's room to administer their medications, which included, insulin sliding scale, 5000 units of heparin subcutaneously, and an IV antibiotic. Staff A stated she administered the sliding scale dose of insulin according to the order in the presence of a second nurse verifier who left the room after the insulin was administered. She then stated that she scanned the heparin and the antibiotic and proceeded to hang the IV antibiotic. She then stated she intended to administer the heparin and she grabbed the vial off the computer tray and drew up 1 ml. and administered the medication to the patient. When she turned around, she noticed the unopened vial of heparin and realized that she had drawn up insulin instead of heparin, administering 100 units of insulin to the patient. During the interview she confirmed that she was talking to the family who was at the patient's bedside, and she just grabbed the vial and drew it up without looking at the label to confirm that it was the heparin.

During a surveyor interview with the Assistant Clinical Manager on 11/20/2023 at 1:30PM she revealed that Staff A entered her office on 11/13/2023 at approximately 2:15PM to notify her of the medication error that was made and that the patient's physician had been notified of the error.