HospitalInspections.org

Based on document review and interview it was determined for 1 of 10 (Pt. #1) clinical records reviewed, the hospital failed to ensure medications were reviewed for accuracy.

Findings include:

1. The "Physician Orders and Medication Guidelines, (revised 4/13) stated in part, "Every 24 hours a Patient Medication Summary is generated. Any medication due for cancellation will be tagged for physician renewal. This form is filed in the medical record in front of the Physician's order sheet."

2. The "Formulary Items with Default Automatic Stop Value" document provided by pharmacy on 7/18/13 included, "Clozapine 100 mg (milligram) has an ASO (automatic stop order) of 8 days.

3. The clinical record of Pt. #1 was reviewed on 7/16/13. Pt. #1 was a 49 year old male admitted on 6/1/13 with the diagnosis of small bowel obstruction. The medication reconciliation form dated 6/3/13 (post operatively) documented Clozapine was ordered as 500 mg daily at bedtime. The medication administration record (MAR) indicated that 500 mg was administered daily from 6/4/13 to 6/12/13. On 6/12/13 the medication was discontinued due to the automatic stop process. A physician's order dated 6/21/13 included Clozapine 100 mg daily at bedtime. The next physician's order for Clozapine dated 7/2/13 decreased the dose to 50 mg daily at bedtime.

3. The hospitalist (MD#1) for Pt. #1 was interviewed on 7/16/13 at 9:30 AM. MD#1 stated, "I was made aware that the patient had not been receiving his Clozapine because the pharmacy has an automatic stop for this medication. I reordered the medication as it was previously ordered. The Clozapine was given as ordered, but never should have been stopped."

4. The Director of Pharmacy (E#4) was interviewed on 7/17/13 at 1:35 PM. E#4 stated,
"We have certain medications that have a default automatic stop date, meaning that when that medication is ordered, the computer automatically discontinues the medication after the predetermined time."

5. The nurse (E#6) caring for Pt. #1 during the medication clarification was interviewed on 7/17/13 at 2:30 PM. E#6 stated Pt. #1 asked about his Clozapine. E#6 looked up why he was not receiving the medication and noticed that it had been stopped by the pharmacy. E#6 called the doctor and got the medication reordered and administered it. " E#6 stated all nurses are responsible for their patients medications and should be aware of what the patient has taken and the reason for it. The nursing staff should question any medications concerns when they happen with the physician.

6. During an interview on 7/18/13 at 2:00 PM the Vice President of Patient Care Services stated, "since we have gone to the computer system, we no longer have a paper medication reconciliation process available to the nursing staff. The medication should have been reordered."