HospitalInspections.org

Based on review of facility documents, observation and staff interviews [EMP], it was determined that Tyrone Hospital failed to ensure that access to concentrated potassium solutions was restricted, and failed to ensure that all prescribers medication orders were reviewed for appropriateness by a pharmacist before the first dose is dispensed, and failed to ensure that medications are prepared and stored safely.

Findings include:

Review of "Tyrone Hospital Pharmacy Department, Job Description, Director of Pharmacy. ... The Director of Pharmacy: 1. Is completely responsible for the procurement, storage, and dispensing of medications. A. Provides for the pick-up of orders and delivery of medications. B. Interprets physicians' medication orders for therapeutic effect, dosage, and route of administration ... D. Compounds, admixes, labels, and dispenses physician's orders in accordance with local state and federal regulations. ...G. Provides for the availability of emergency and non-emergency drugs to patient care areas during times when the pharmacy is closed. H. Assures that medications are stored properly and safely throughout the hospital. ... ."

Review of "Tyrone Hospital Standard of Practice: Potassium Chloride" effective May 2002, revealed, " In the interests of patient safety, potassium chloride concentrated vials will not be stocked in the Nursing Units. Whenever possible, pre-mixed solutions of potassium chloride will be available ... "

1) A tour of the Emergency Department on June 16, 2011 at approximately 1:30 PM, revealed eight vials of 20 meq of potassium chloride concentrate on the medicine shelf.

EMP1 confirmed the above findings.

Interview with EMP1 on June 16, 2011 at approximately 2:00 PM, revealed, "We keep four - 40 meq potassium chloride concentrated vials, four-30 meq potassium chloride concentrated vials, three - 20 meq potassium chloride concentrated vials, and three- 10 meq vials of potassium chloride concentrated vials in the night cabinet. Pharmacy just removed the potassium vials from the night cabinet located on the Med Surg area."

Interview with EMP4 on June 17, 2011 at approximately 10:00 AM, revealed, "We (nurses) mix the Potassium and the IV solutions."

Interview with EMP6 on June 17, 2011 at approximately 11:00 AM, revealed, "I mixed it one time, the ones [Potassium] with the adapters. I have mixed it to a specific order when we
needed a different solution."

Review of "Pharmacy Department Plan Of Care - Staffing 1. The Pharmacy's hours of operation are: A. Monday thru Friday: 08:00 AM to 1:00 PM, Saturday: 07:30 AM to 9:00 AM, Sunday: 10:00 AM to 12:00 noon B. Holidays: The Pharmacy will be closed in observation of New Year's Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving, and Christmas Day. ... 1. A Pharmacist will be in the hospital from 8:00 AM until 1:00 PM Monday to Friday. After the pharmacist leaves the hospital at 1:00 PM: *Nursing will fax new orders using the original sheet to .... (off site Pharmacy) ... will not be able to fill any faxed orders after 6:00 PM * Nursing supervisor are to obtain the needed medications from the night locker after 6 :00 PM. ... "

Review of "Tyrone Hospital Off-Campus Medication Procedure, August 2006. Nursing supervisors will fax medication orders to the off-site pharmacy during the hours of: Monday through Friday 1:00 PM until 7:00 PM, Saturday 9:00 AM until 4:00 PM, Sunday 12 noon until 3:00 PM. These medication orders will be filled at the off-site pharmacy and be available for pick up by the designated hospital employee ... Medications that need to be started before the next scheduled delivery time can be obtained by the nursing supervisor from the on campus after hour hospital pharmacy room. The nursing supervisor will fax a copy of the order to the off site pharmacy and state on the order which medications they are obtaining and the quantity they are taking. The off site pharmacist will review the medication order for drug interactions and any possible drug allergy problems. If there is an emergency situation that a patient needs medication that is not available in the pharmacy night locker the nursing supervisor shall follow this procedure: * Contact the on call pharmacist and inform the pharmacist of the emergency situation * The pharmacist will give the nursing supervisor two options to get the necessary medication (1) if the medication is needed immediately the nursing supervisor will be given the lock code to gain entrance to the hospital pharmacy (2) if the medication is not needed immediately but will be needed before the next scheduled opening of the pharmacy, the on call pharmacist will go (sic)the hospital pharmacy and supply the needed medication. ..."

2. An interview with EMP7 on June 16, 2011, at 1:30 PM, revealed, " After hours orders are not reviewed by Pharmacy until the following day."

An interview with EMP8 on June 16, 2011, at approximately 3:00 PM, confirmed the above finding. EMP8 stated "Medications are taken out of the night cabinet. The medication orders are not reviewed by Pharmacy until the following day, this would include any new admissions. We are having an issue with some supervisors taking all the ordered medications from the cabinet. Some of the medications should not be removed from the night cabinet as they are medications that the patient may have already taken at home."

Review of "Tyrone Hospital Standard of Practice: Outdated Medications. Outdated and/or unusable medications shall be removed and stored away from usable stock medications until proper disposition can be effected: 1. The entire Pharmacy stock is examined twice yearly and a list is made, by month, of all drugs due to expire during the next six months. The outdated goods are then pulled from stock on a monthly basis. ... 2. Routine inspections of all medication storage areas are performed on a monthly basis by the pharmacy staff and expired and outdated medications are pulled. 3. When outdated medications are found in the Pharmacy or any medication storage area, the medication shall immediately pulled from stock. ... "

3. A tour of Tyrone Hospital on June 17, 2011, revealed expired medications in the following locations.

A tour of the Surgical Services Department on June 17, 2011, at approximately 1:30 PM, revealed that three boxes (six vials per box) of Dantrolene Sodium 20 mg housed in the Malignant Hyperthermia cart, had expired May 2011.

Interview with EMP9 on June 17, 2011, at approximately 1:45 PM, confirmed the above findings.

A tour of the Post Anesthesia Care Unit (PACU) on June 17, 2011, at approximately 2:00 PM, revealed that in the medication floor stock that three Epinephrine Injection 1:1000 (1 mg/ml) had expired October 2010, and two Propranolol Hydrochloride Injection (1 mg/ml) had expired September 2010.

Interview with EMP9 on June 17, 2011, at approximately 2:00 PM, confirmed the above findings.

A tour of the Pain Clinic on June 17, 2011, at approximately 12:45 PM, revealed that in the medication cabinet there were 10 boxes of Zanaflex Capsules 2 mg per capsule (six pills per box) that had expired December 2010 and 36 packs of Skelaxin 800 mg (four pills per packet) had expired May 2010.

Interview with EMP10 on June 17, 2011, at approximately 1:00 PM, confirmed the above findings. EMP10 stated that "pharmacy never comes and and checks our medications."

The Pain Clinic Medication Storage area revealed that 17 different medications were being stored in the medication cabinet. One of the 17 medications was not on the hospital formulary.

Interview with EMP7 on June 17, 2011, at approximately 2:45 PM revealed "I did not know that there was any medication stored in the Pain Clinic, they must be samples from drug companies."