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Based on review of documentation and interviews with the facility staff, the facility failed to ensure that all drugs are administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, and in accordance with the approved medical staff policies and procedures as evidenced by the nurse leaving medication unsecured in patient's room and the oral medication being accidentally given through intravenous line by patient's father's girlfriend. Patients at the facility could suffer death or severe impairment if unauthorized users are permitted to administer medications to patients receiving care at the hospital.

Cross refer: A0405

Based on review of documentation and interviews with the facility staff, the facility failed to ensure that all drugs are administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, and in accordance with the approved medical staff policies and procedures as evidenced by the nurse leaving medication unsecured in patient's room and the oral medication being accidentally given through intravenous line by patient's father's girlfriend. Patients at the facility could suffer death or severe impairment if unauthorized users are permitted to administer medications to patients receiving care at the hospital.

The findings were:

The facility document titled, "Medication Administration and Monitoring," states, "Medication administration procedures will be followed to ensure patient safety. Medical City Dallas follow the Seven Rights of Medication Administration, including: Right patient; Right medication; Right dose; Right route; Right time; Right documentation; Right reason ...Other key safety practices include: Medications should be administered directly to the patient and never left at the bedside, (observe the patient to ensure he/she takes the medication) ... Report any medication errors or adverse drug reactions immediately to the prescribing physician and document according to established procedure." This policy was last approved on February 2023.


The complete medical record of Patient #1's hospital admission was reviewed on 9/12/23 with the VP of Quality Management (Staff #3), it was noted:
- Nursing note on 9/9/23 0520: "At 0520 nurse enters pt room to adminster [sic] scheduled po tyleonol [sic], at time of entry step mom in the room requested that we wait and she give the medicine in about 30 mins due to the patient being asleep and she wanted to wait a little bit longer, nurse agreed (nurse visualized step mom administering [sic] po medication on other scheduled doses earlier in the night due to patient being more compliant when step mom would give the medicine) at about 0525 nurse notified of iv complications, upon entering the room father and stepmom at bedside informed of step mom attempting to put po medication through [sic] iv, nurse assessed iv site and iv line, iv removed due to tylenol medication visable in the line, gauze and tape adhered to iv site, father and step mom educated of error, and potential complications, charge nurse notified, Dr [hospitalist] notified, [doctor] gave telephone orders to dc iv order, also notified birth mother, birth mother stated she would be coming up to the hospital to visit her son and address the situation."
- Orthopedic Progress Note on 9/9/23 1255: "Regarding the events early this morning:
Read nurse notes and spoke with charge nurse: early this morning, pt's step mother in room and offered to give PO Tylenol elixir when pt awoke, nurse returned and pt's step mother was attempting to give medication via PIV. None of the medication went into vein as it was stuck in tubing. Pt's birth mother came shortly after to remain with patient. We have no concerns about patient going home today with birth mother. I did have an extensive conversation with the social work team who will follow up with the patient to take the appropriate steps to alert CPS, but that can be done on an outpatient basis from ortho standpoint. Since none of the medication was actually delivered into the vein, we do not feel it is necessary to continue monitoring patient from an AE standpoint/contact poison control/etc. Pt seen with Dr [hospitalist]
- Case Management note on 9/9/23 1514: "SW [social worker] received phone call regarding incident in room this morning. Per pt nurse note, pts fathers girlfriend reportedly asked if she could wait 30 minutes to give pt his medication so that he could sleep longer. Pts nurse reportedly left a syringe of oral Tylenol in the pts room. Pts fathers girlfriend apparently gave the pt his medication through his IV. Pts nurse reportedly came back at a later time and noticed the Tylenol in the IV. Pts provider informed and IV was dc. Pts father and fathers girlfriend were reportedly then educated by nurse ..."


The Patient Safety Analysis - Medication Report on 9/9/23 0631 states:
Medication Error Type: Wrong
Medication Error Wrong: Wrong Route
Medication Name: Tylenol
Expected Route: Oral
Administered Route: IV Push
Brief Objective Description: Pateints [sic] stepmom attempted to administer PO medication into IV.
Reporter Additional Comments: pateints [sic] mstep mom at bedside attempted to administer [sic] PO medication into IV. Nurse entered room to administer PO Tylenol to patient, at time of entry step mom asked to wait a few minutes to wake pt, and if she could give po medication, notified pts step mom nurse would be back shortly to administer med/cation after she was ready to awaken pt, syringe medication at side table, call light put on shortly after, nurse entered, step mom notified nurse that she attempted to put PO medication into IV. IV dced, Dr on call notified, nurse supervisor notified.


A written statement provided by Staff #1 (LVN that took care of Patient #1) on 9/12/23 states, "What I remember from the medication error event that took place on the morning of 9/9/23: Patients PO TYLENOL was scheduled for 0500, I drew up medicine in a syringe in the medicine room, took medicine to patients room, scanned patients arm band and medicine. Attempted to awake Step mom and father at bedside to inform them I would be awakening patient from rest to administer medication. Step mom, requested that the medication not be administered at this time and not to awaken the patient at this time due to patient lack of rest throughout shift. Nurse agreed informed step mom at bedside that the nurse would be back within a few minutes to administer medication/witness administration. Nurse included father and step mom in patient care throughout shift patient incompliance and previously throughout the night, patient only taking oral medicine from the parents at the bedside while nurse at bedside to witness. Approximately a few minutes later the charge nurse informed nurse that there was an issue with the IV in patients room. Nurse entered room to assess IV, father and step mom at bedside, father stated 'I woke up and she was trying to put the medicine in the IV' referring to the step mom, nurse assessed IV and could see a small amount of medication in the IV line. IV site was clear, dry and intact with no signs or symptoms of complications at this time. Nurse had another nurse on the floor assess the IV site, and with that same nurse the IV access was removed for safety. Charge nurse notified, surgeon notified, and birth mother notified. Nurse entered room to inform family of actions taken. The nurse informed the father and stepmom of potential complications. Stepmom asked the nurse 'well it's going to be fine right?' the nurse replied and informed stepmom and father at the bedside that although the site was without signs or symptoms of complications at this time, complications could result from the event, father, and stepmom verbalized understanding."


A written statement provided by Staff #5 (Director of Pediatric Services) on 9/12/23 states, "I was made aware of the event Saturday morning 9/9/23. The day shift charge nurse explained to me that the mother of the patient had accidentally attempted to give oral Tylenol through the patients IV. I was told the medication never made it to the patient and that all assessments had been within normal limits. I confirmed that a physician had been made aware of the event and inquired about the overall status of the patient. I was told that the patient was fine with no issues and would likely be discharged that day. Monday morning during huddle I spoke with nursing staff about the event and reminded them of the risks and the necessity to always put oral medications in oral syringes and IV medications in IV syringes. I also reeducated that we are never to leave medications at the bedside and that we are responsible for administering. I also had the intention of including this in Friday updates. In terms of following up with this directly, I planned on doing this on Friday 9/15 when she returned to work."