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Based on interviews and documentation review, it was determined Hospital Staff failed to effectively communicate a pre-established Patient/Neonate Care Plan resulting in inappropriate interruption in the breastfeeding of 1 of 1 applicable neonates (Neonate #1) and Hospital staff were aware of this issue, but had not (yet) fully developed and implemented a Corrective Action Plan.

Findings included:

A review of Patient #1's medical record revealed it included her Prenatal Record and a Prenatal Patient Care Conference Note dated 1/10/11.

The Prenatal Record record indicated Patient #1 was on Subutex for heroin addiction, she had not used heroin since 5/09, she was being seen/followed by a Maternal-Fetal Medicine Physician (in addition to her regular Obstetrician), and her estimated date of delivery was 2/14/11.

Information regarding Subutex (buprenorphine hydrochloride) indicated it is a partial agonist-antagonist opioid analgesic that has a high affinity to opioid receptors and was FDA-approved for the treatment of opioid addiction in October, 2002. Subutex blocks other opioids while allowing for some opioid effect of its own, and enables opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms and cravings. Subutex therapy maintains some of the preexisting physical dependence which is eventually resolved with a slow taper (off the Subutex). The usual adult dose of Subutex for treatment of opioid addiction is 12-16 milligrams (mgs); sublingually (under the tongue), in a single daily dose. Adverse reactions include lightheadedness, dizziness, drowsiness, sedation, and respiratory depression. Alcohol, other narcotics and pain medications, tranquilizers, sedatives and muscle relaxants may increase the CNS depression of Subutex and are to be avoided. Subutex is a FDA Pregnancy Risk Category C (risk cannot be ruled out) drug. Subutex taken during pregnancy causes fetal/neonate dependence. Subutex passes into breast milk and is a Lactation Risk Category 2 (between moderately safe and safest) drug.

The Prenatal Patient Care Conference Note indicated the Conference was attended by Patient #1, Patient #1's Mother, Anesthesiologist #1, Pediatric Hospitalist #1 (a hospitalist is a physician who cares for hospitalized patients either in lieu of, or in conjunction with primary care physicians), Nurse Manager #1, Case Manager #1 and Social Worker #1. The Conference Note also indicated: Patient #1 was on Subutex for a history of heroin addiction; her last documented time of heroin use was 5/17/09; she took 16 mgs of Subutex every morning and night; she planned to use Pediatrician #2 (the Primary Care Pediatrician) and to breastfeed; Anesthesiologist #1 discussed labor, delivery and postpartum pain management and; Pediatric Hospitalist #1 discussed Neonatal Abstinence Syndrome (NAS; a complex disorder caused by the prenatal maternal use of substances that result in withdrawal symptoms in the neonate).

Pediatric Hospitalist #1 was interviewed by telephone at 2:30 PM on 3/23/11. He said Subutex was a class C medication and not technically "approved" for use during pregnancy and/or breastfeeding, but he had consulted with neonatologists at an affiliated tertiary care hospital, and the neonatologists had indicated it was "OK" to breastfeed while on Subutex. Pediatric Hospitalist #1 said this was discussed at Patient #1's Prenatal Care Conference and although Patient #1 seemed a little undecided about breastfeeding, she said the plan was to breastfeed. Pediatric Hospitalist #1 said he also told Patient #1 that if she chose to breastfeed, she needed to breastfeed consistently and thoroughly to keep the neonate's blood level of Subutex consistent and prevent/minimize NAS.

Medical record documentation indicated Patient #1 presented to the Hospital's Obstetrical Department in labor and on 40 mgs of Subutex/day on the evening of 2/18/11. Shortly thereafter, Patient #1 underwent a cesarean section with spinal anesthesia for a non-reassuring fetal heart rate. Neonate #1 was born at 10:12 PM and had Apgar Scores of 8 and 9 (Apgar Scores of 7-10 indicate the neonate is in good to excellent condition).

Patient #1's Postoperative Physician Orders included an order for Subutex 40 mgs/day.

Neonate #1's Post-Delivery Orders indicated that if being breastfed, he/she should be breastfed on demand; at least every 3 hours, and if being formula fed, he/she should receive formula with iron every 4 hours; as tolerated.

Admission documentation completed after the delivery of Neonate #1 (because the cesarean section was emergent) indicated Patient #1 was planning on breastfeeding.

Documentation indicated Patient #1 gave permission for Neonate #1 to be cup fed X1 during the night of 2/18-2/19/11 so she could sleep.

The registered nurse assigned to care for Neonate #1 on the 2/19/11 day shift (Staff RN #1) was interviewed in person at 4:00 PM on 3/22/11. She said she had previously cared for neonates born to mothers on Subutex but those neonates had not been breastfed, and when she heard that Neonate #1 was to be breastfed; she told the pediatrician covering for Neonate #1's Primary Care Pediatrician (Pediatrician #3) that neonates born to mothers on Subutex had not previously been breastfed, and considering this and Patient #1's (high) Subutex dose, she was concerned about Neonate #1 being breastfed. Staff RN #1 said Pediatrician #3 said he didn't know anything about Subutex and breastfeeding, but he would look into it, and get back to her.

Staff RN #1 said Pediatrician #3 did some on-line research into Subutex and spoke with Lactation Consultant #1, and then; indicated he needed to do some homework, and in the meantime; Neonate #1 should not be breastfed.

Lactation Consultant #1 was interviewed in person at 8:10 AM on 3/23/11. She said Pediatrician #3 asked her about breastfeeding on Subutex and she told him she would research it and get back to him. Lactation Consultant #1 said she noted the Prenatal Patient Care Conference Note in Patient #1's medical record indicating she was on Subutex and going to breastfeed, but said after consulting her usual reference (Medications and Mother's Milk [Hale Publishing; 2010]) and noting Subutex was a pregnancy risk category C and a lactation risk category L2 drug with a long half-life and noting Patient #1's (high) daily dose, she was not comfortable making a recommendation regarding Patient #1/Neonate #1 breastfeeding. Lactation Consultant #1 reported relaying this information to Pediatrician #3 and taking a Telephone Order from Pediatrician #3 to discontinue Neonate #1's breastfeeding.

Documentation indicated Lactation Consultant #1 took the Telephone Order to discontinue Neonate #1's breastfeeding at 9:05 AM.

Lactation Consultant #1 reported discussing her and Pediatrician #3's reservations about breastfeeding and breast-pumping (in case further research on Subutex indicated breastfeeding was "OK") with Patient #1. Lactation Consultant #1 said Patient #1's Mother then entered the room and began quizzing her about Subutex. Lactation Consultant #1 said she reported her research and reservations regarding breastfeeding on Subutex to Patient #1's Mother and the Mother said breastfeeding on Subutex was "OK" and immediately placed a telephone call to the physician she said prescribed the Subutex. Lactation Consultant #1 said that at the Mother's insistence, she spoke with the Physician (not a physician on the Hospital's medical staff), and told him about her research and reservations regarding breastfeeding on Subutex. She said the Physician said there was newer research (reported in 1/11) and the newer research indicated it was "OK" to breastfeed while on Subutex. Lactation Consultant #1 said Patient #1's Mother wanted her to call other hospitals regarding breastfeeding and Subutex and she told the Mother she would call Pediatrician #3.

Lactation Consultant #1 reported telephoning Pediatrician #3 to tell him about her conversations with Patient #1's Mother and the Physician who prescribed Patient #1's Subutex. She said Pediatrician #3 indicated he had just gotten off the phone with Patient #1's Mother, and it was "OK" for Patient #1 to breastfeed. Lactation Consultant #1 said Pediatrician #3 said he had not had communication from the Primary Care Pediatrician (one of his partners) regarding Patient #1 breastfeeding on Subutex.

Documentation indicated that at 11:15 AM, Pediatrician #3 gave Lactation Consultant #1 the following Telephone Order: Infant may be breastfed for the weekend - Please re-evaluate on Tuesday, 2/22/11.

The Primary Care Pediatrician was interviewed by telephone at 12:10 PM on 3/23/10. He said he was not informed of Patient #1's Prenatal Patient Care Conference.

Pediatric Hospitalist #1 said newborns are generally on the Hospitalist Service (while hospitalized). He said Patient #1 chose a pediatrician from the one Pediatric Group Practice affiliated with the Hospital that does not utilize the Hospitalist Service and the information discussed at Patient #1's Prenatal Patient Care Conference was not communicated to the Primary Care Pediatrician and/or well documented in the Conference Note.

Medical record documentation indicated Patient #1 attempted to breastfeed Neonate #1 at 11:30 AM but the Neonate was sleepy. Documentation also indicated: Patient #1 attempted to breastfeed Neonate #1 with the assistance of a lactation consultant at 3:15 PM but he/she was mucousy and fell asleep, and Patient #1 requested he/she be given formula by cup; a lactation consultant and/or nurse continued to assist Patient #1 with breastfeeding; Neonate #1 was sleepy; Neonate #1 occasionally received formula by cup (at Patient #1's request); Patient #1 began pumping her breasts with an electric breast pump; Patient #1 expressed colostrum (a thin, yellow breast fluid most evident in the first 2-3 days after birth and before the onset of true lactation; colostrum contains a great number of proteins, calories and immune globulins) and it was fed to Neonate #1; early on the morning of 2/20/11, Patient #1 decided she did not want to breastfeed, but would continue to pump and give Neonate #1 the expressed breast milk (EBM); Neonate #1 was fed EBM and the EBM was supplemented with formula (as needed); Neonate #1 developed NAS symptoms early on the morning of 2/21/11; non-pharmacological NAS management interventions were implemented and; another pediatrician covering for the Primary Care Pediatrician (Pediatrician #4) was notified.

Staff RN #1 said Neonate #1 was evaluated by another pediatrician covering for his/her Primary Care Pediatrician (Pediatrician #5) at 8:50 AM on 2/21/11 and again, she expressed her concern regarding Neonate #1 being breastfed. Staff RN #1 said Pediatrician #5 said he didn't know anything about Subutex and breastfeeding, but he would look into it, and get back to her.

Staff RN #1 said at some point, Patient #1's Mother spoke with Pediatrician #5 and later; Pediatrician #5 telephoned and said it was OK for Patient #1 to breastfeed Neonate #1.

Documentation indicated Pediatrician #5 gave a Telephone Order indicating Patient #1 could breastfeed Neonate #1 at 2:28 PM. Documentation also indicated Neonate #1 took EBM without difficulty and his/her NAS symptoms resolved.

The Obstetric Nurse Manager was interviewed in person at 8:30 AM on 3/22/11. She said she became aware of the issues regarding Patient #1 breastfeeding Neonate #1 on 2/22/11 and an investigation of the issues revealed Patient #1's Prenatal Patient Care Conference was not well communicated and/or documented. She also said the Obstetric Department was working on a Corrective Action Plan related to Prenatal Patient Care Conferences, it had already been decided that a lactation consultant would attend each Conference, and the Corrective Action Plan would include staff and physician education regarding breastfeeding on Subutex.

Pediatric Hospitalist #1 said that since the issues related to the poor communication of Patient #1's Prenatal Patient Care Conference, he has been writing formal notes regarding the Conferences he attends and forwarding them to each patient's obstetrician, the designated primary care pediatrician, and the Obstetric Nurse Manager.

A formal Corrective Action Plan had not (yet) been developed.

Based on interviews and documentation review, it was determined Hospital Staff had not (yet) fully developed and implemented a Corrective Action Plan related to its failure to effectively communicate a pre-established Patient/Neonate Care Plan resulting in inappropriate interruption in the breastfeeding of 1 of 1 applicable neonates (Neonate #1) and therefore had not (yet) developed a related Quality Monitoring Plan.

Findings included:

Please see Tag A 288 for information regarding the pre-established Patient/Neonate Care Plan, Neonate #1 and the interruption in Neonate #1's breastfeeding.

Because Hospital Staff had not (yet) fully developed and implemented a Corrective Action Plan related to its failure to effectively communicate a pre-established Patient #1/Neonate #1 Care Plan, a related Quality Monitoring Plan had not (yet) been developed.

Based on documentation review, it was determined Anesthesiologist #3 incorrectly documented that 1 of 1 applicable patients (Patient #1) was on methadone when she was actually on Subutex.

Findings included:

Please see Tag A 0288 for information regarding Patient #1, Subutex and Patient #1's Subutex therapy.

Documentation on Patient #1's 2/18/11 Anesthesia Record indicated she was on methadone.

Subutex is a partial agonist-antagonist opioid analgesic sometimes utilized for treatment of opioid addiction.

Methadone is a full agonist opioid analgesic sometimes utilized for treatment of opioid addiction.

There was no evidence that Patient #1 had any type of medication or pain issue related to this incorrect documentation however, the potential for an issue existed.

Based on interviews and documentation review, it was determined Hospital Staff failed to effectively communicate a pre-established Patient/Neonate Care Plan resulting in inappropriate interruption in the breastfeeding of 1 of 1 applicable neonates (Neonate #1) and Hospital staff were aware of this issue, but had not (yet) fully developed and implemented a Corrective Action Plan.

Findings included:

A review of Patient #1's medical record revealed it included her Prenatal Record and a Prenatal Patient Care Conference Note dated 1/10/11.

The Prenatal Record record indicated Patient #1 was on Subutex for heroin addiction, she had not used heroin since 5/09, she was being seen/followed by a Maternal-Fetal Medicine Physician (in addition to her regular Obstetrician), and her estimated date of delivery was 2/14/11.

Information regarding Subutex (buprenorphine hydrochloride) indicated it is a partial agonist-antagonist opioid analgesic that has a high affinity to opioid receptors and was FDA-approved for the treatment of opioid addiction in October, 2002. Subutex blocks other opioids while allowing for some opioid effect of its own, and enables opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms and cravings. Subutex therapy maintains some of the preexisting physical dependence which is eventually resolved with a slow taper (off the Subutex). The usual adult dose of Subutex for treatment of opioid addiction is 12-16 milligrams (mgs); sublingually (under the tongue), in a single daily dose. Adverse reactions include lightheadedness, dizziness, drowsiness, sedation, and respiratory depression. Alcohol, other narcotics and pain medications, tranquilizers, sedatives and muscle relaxants may increase the CNS depression of Subutex and are to be avoided. Subutex is a FDA Pregnancy Risk Category C (risk cannot be ruled out) drug. Subutex taken during pregnancy causes fetal/neonate dependence. Subutex passes into breast milk and is a Lactation Risk Category 2 (between moderately safe and safest) drug.

The Prenatal Patient Care Conference Note indicated the Conference was attended by Patient #1, Patient #1's Mother, Anesthesiologist #1, Pediatric Hospitalist #1 (a hospitalist is a physician who cares for hospitalized patients either in lieu of, or in conjunction with primary care physicians), Nurse Manager #1, Case Manager #1 and Social Worker #1. The Conference Note also indicated: Patient #1 was on Subutex for a history of heroin addiction; her last documented time of heroin use was 5/17/09; she took 16 mgs of Subutex every morning and night; she planned to use Pediatrician #2 (the Primary Care Pediatrician) and to breastfeed; Anesthesiologist #1 discussed labor, delivery and postpartum pain management and; Pediatric Hospitalist #1 discussed Neonatal Abstinence Syndrome (NAS; a complex disorder caused by the prenatal maternal use of substances that result in withdrawal symptoms in the neonate).

Pediatric Hospitalist #1 was interviewed by telephone at 2:30 PM on 3/23/11. He said Subutex was a class C medication and not technically "approved" for use during pregnancy and/or breastfeeding, but he had consulted with neonatologists at an affiliated tertiary care hospital, and the neonatologists had indicated it was "OK" to breastfeed while on Subutex. Pediatric Hospitalist #1 said this was discussed at Patient #1's Prenatal Care Conference and although Patient #1 seemed a little undecided about breastfeeding, she said the plan was to breastfeed. Pediatric Hospitalist #1 said he also told Patient #1 that if she chose to breastfeed, she needed to breastfeed consistently and thoroughly to keep the neonate's blood level of Subutex consistent and prevent/minimize NAS.

Medical record documentation indicated Patient #1 presented to the Hospital's Obstetrical Department in labor and on 40 mgs of Subutex/day on the evening of 2/18/11. Shortly thereafter, Patient #1 underwent a cesarean section with spinal anesthesia for a non-reassuring fetal heart rate. Neonate #1 was born at 10:12 PM and had Apgar Scores of 8 and 9 (Apgar Scores of 7-10 indicate the neonate is in good to excellent condition).

Patient #1's Postoperative Physician Orders included an order for Subutex 40 mgs/day.

Neonate #1's Post-Delivery Orders indicated that if being breastfed, he/she should be breastfed on demand; at least every 3 hours, and if being formula fed, he/she should receive formula with iron every 4 hours; as tolerated.

Admission documentation completed after the delivery of Neonate #1 (because the cesarean section was emergent) indicated Patient #1 was planning on breastfeeding.

Documentation indicated Patient #1 gave permission for Neonate #1 to be cup fed X1 during the night of 2/18-2/19/11 so she could sleep.

The registered nurse assigned to care for Neonate #1 on the 2/19/11 day shift (Staff RN #1) was interviewed in person at 4:00 PM on 3/22/11. She said she had previously cared for neonates born to mothers on Subutex but those neonates had not been breastfed, and when she heard that Neonate #1 was to be breastfed; she told the pediatrician covering for Neonate #1's Primary Care Pediatrician (Pediatrician #3) that neonates born to mothers on Subutex had not previously been breastfed, and considering this and Patient #1's (high) Subutex dose, she was concerned about Neonate #1 being breastfed. Staff RN #1 said Pediatrician #3 said he didn't know anything about Subutex and breastfeeding, but he would look into it, and get back to her.

Staff RN #1 said Pediatrician #3 did some on-line research into Subutex and spoke with Lactation Consultant #1, and then; indicated he needed to do some homework, and in the meantime; Neonate #1 should not be breastfed.

Lactation Consultant #1 was interviewed in person at 8:10 AM on 3/23/11. She said Pediatrician #3 asked her about breastfeeding on Subutex and she told him she would research it and get back to him. Lactation Consultant #1 said she noted the Prenatal Patient Care Conference Note in Patient #1's medical record indicating she was on Subutex and going to breastfeed, but said after consulting her usual reference (Medications and Mother's Milk [Hale Publishing; 2010]) and noting Subutex was a pregnancy risk category C and a lactation risk category L2 drug with a long half-life and noting Patient #1's (high) daily dose, she was not comfortable making a recommendation regarding Patient #1/Neonate #1 breastfeeding. Lactation Consultant #1 reported relaying this information to Pediatrician #3 and taking a Telephone Order from Pediatrician #3 to discontinue Neonate #1's breastfeeding.

Documentation indicated Lactation Consultant #1 took the Telephone Order to discontinue Neonate #1's breastfeeding at 9:05 AM.

Lactation Consultant #1 reported discussing her and Pediatrician #3's reservations about breastfeeding and breast-pumping (in case further research on Subutex indicated breastfeeding was "OK") with Patient #1. Lactation Consultant #1 said Patient #1's Mother then entered the room and began quizzing her about Subutex. Lactation Consultant #1 said she reported her research and reservations regarding breastfeeding on Subutex to Patient #1's Mother and the Mother said breastfeeding on Subutex was "OK" and immediately placed a telephone call to the physician she said prescribed the Subutex. Lactation Consultant #1 said that at the Mother's insistence, she spoke with the Physician (not a physician on the Hospital's medical staff), and told him about her research and reservations regarding breastfeeding on Subutex. She said the Physician said there was newer research (reported in 1/11) and the newer research indicated it was "OK" to breastfeed while on Subutex. Lactation Consultant #1 said Patient #1's Mother wanted her to call other hospitals regarding breastfeeding and Subutex and she told the Mother she would call Pediatrician #3.

Lactation Consultant #1 reported telephoning Pediatrician #3 to tell him about her conversations with Patient #1's Mother and the Physician who prescribed Patient #1's Subutex. She said Pediatrician #3 indicated he had just gotten off the phone with Patient #1's Mother, and it was "OK" for Patient #1 to breastfeed. Lactation Consultant #1 said Pediatrician #3 said he had not had communication from the Primary Care Pediatrician (one of his partners) regarding Patient #1 breastfeeding on Subutex.

Documentation indicated that at 11:15 AM, Pediatrician #3 gave Lactation Consultant #1 the following Telephone Order: Infant may be breastfed for the weekend - Please re-evaluate on Tuesday, 2/22/11.

The Primary Care Pediatrician was interviewed by telephone at 12:10 PM on 3/23/10. He said he was not informed of Patient #1's Prenatal Patient Care Conference.

Pediatric Hospitalist #1 said newborns are generally on the Hospitalist Service (while hospitalized). He said Patient #1 chose a pediatrician from the one Pediatric Group Practice affiliated with the Hospital that does not utilize the Hospitalist Service and the information discussed at Patient #1's Prenatal Patient Care Conference was not communicated to the Primary Care Pediatrician and/or well documented in the Conference Note.

Medical record documentation indicated Patient #1 attempted to breastfeed Neonate #1 at 11:30 AM but the Neonate was sleepy. Documentation also indicated: Patient #1 attempted to breastfeed Neonate #1 with the assistance of a lactation consultant at 3:15 PM but he/she was mucousy and fell asleep, and Patient #1 requested he/she be given formula by cup; a lactation consultant and/or nurse continued to assist Patient #1 with breastfeeding; Neonate #1 was sleepy; Neonate #1 occasionally received formula by cup (at Patient #1's request); Patient #1 began pumping her breasts with an electric breast pump; Patient #1 expressed colostrum (a thin, yellow breast fluid most evident in the first 2-3 days after birth and before the onset of true lactation; colostrum contains a great number of proteins, calories and immune globulins) and it was fed to Neonate #1; early on the morning of 2/20/11, Patient #1 decided she did not want to breastfeed, but would continue to pump and give Neonate #1 the expressed breast milk (EBM); Neonate #1 was fed EBM and the EBM was supplemented with formula (as needed); Neonate #1 developed NAS symptoms early on the morning of 2/21/11; non-pharmacological NAS management interventions were implemented and; another pediatrician covering for the Primary Care Pediatrician (Pediatrician #4) was notified.

Staff RN #1 said Neonate #1 was evaluated by another pediatrician covering for his/her Primary Care Pediatrician (Pediatrician #5) at 8:50 AM on 2/21/11 and again, she expressed her concern regarding Neonate #1 being breastfed. Staff RN #1 said Pediatrician #5 said he didn't know anything about Subutex and breastfeeding, but he would look into it, and get back to her.

Staff RN #1 said at some point, Patient #1's Mother spoke with Pediatrician #5 and later; Pediatrician #5 telephoned and said it was OK for Patient #1 to breastfeed Neonate #1.

Documentation indicated Pediatrician #5 gave a Telephone Order indicating Patient #1 could breastfeed Neonate #1 at 2:28 PM. Documentation also indicated Neonate #1 took EBM without difficulty and his/her NAS symptoms resolved.

The Obstetric Nurse Manager was interviewed in person at 8:30 AM on 3/22/11. She said she became aware of the issues regarding Patient #1 breastfeeding Neonate #1 on 2/22/11 and an investigation of the issues revealed Patient #1's Prenatal Patient Care Conference was not well communicated and/or documented. She also said the Obstetric Department was working on a Corrective Action Plan related to Prenatal Patient Care Conferences, it had already been decided that a lactation consultant would attend each Conference, and the Corrective Action Plan would include staff and physician education regarding breastfeeding on Subutex.

Pediatric Hospitalist #1 said that since the issues related to the poor communication of Patient #1's Prenatal Patient Care Conference, he has been writing formal notes regarding the Conferences he attends and forwarding them to each patient's obstetrician, the designated primary care pediatrician, and the Obstetric Nurse Manager.

A formal Corrective Action Plan had not (yet) been developed.

Based on interviews and documentation review, it was determined Hospital Staff had not (yet) fully developed and implemented a Corrective Action Plan related to its failure to effectively communicate a pre-established Patient/Neonate Care Plan resulting in inappropriate interruption in the breastfeeding of 1 of 1 applicable neonates (Neonate #1) and therefore had not (yet) developed a related Quality Monitoring Plan.

Findings included:

Please see Tag A 288 for information regarding the pre-established Patient/Neonate Care Plan, Neonate #1 and the interruption in Neonate #1's breastfeeding.

Because Hospital Staff had not (yet) fully developed and implemented a Corrective Action Plan related to its failure to effectively communicate a pre-established Patient #1/Neonate #1 Care Plan, a related Quality Monitoring Plan had not (yet) been developed.

Based on documentation review, it was determined Anesthesiologist #3 incorrectly documented that 1 of 1 applicable patients (Patient #1) was on methadone when she was actually on Subutex.

Findings included:

Please see Tag A 0288 for information regarding Patient #1, Subutex and Patient #1's Subutex therapy.

Documentation on Patient #1's 2/18/11 Anesthesia Record indicated she was on methadone.

Subutex is a partial agonist-antagonist opioid analgesic sometimes utilized for treatment of opioid addiction.

Methadone is a full agonist opioid analgesic sometimes utilized for treatment of opioid addiction.

There was no evidence that Patient #1 had any type of medication or pain issue related to this incorrect documentation however, the potential for an issue existed.