HospitalInspections.org

Based on observation, policy review and staff interview the hospital failed to ensure outdated drugs and biologicals were not available for patient use in one of one medication tray located in a drug cabinet, one of one anesthesia medication cart and one of one supply storage room. This deficient practice has the potential for patients to receive contaminated ineffective medications and biologicals.

Findings include:

- Observation in the operating room area on 1/8/18 at 3:30pm revealed a "drug cabinet" with silver metal closed boxes that contained medications for use by anesthesia staff. One of the boxes contained an opened 30cc (cubic centimeter) of 0.9% sodium chloride (a salt solution) for injection without a date when opened.

- Observation in the operating room area on 1/8/18 at 3:30pm revealed an anesthesia medication cart with multiple draws that contained multiple medications that anesthesia staff used. The following opened medication vials lacked a date that indicated the open date.

1- 10cc vial of Dexamethasone (a steroid used for some allergic or inflammatory conditions).
1- 30cc vial of 0.9% sodium chloride
The cart also contained 1-10cc vial of Neostigmine (medication used to reverse the effects of anesthesia) that was open with a date written on it of 12/5/17.

Administrative staff B interviewed on 1/8/18 at 3:30pm confirmed the opened vials of medication lacked a date when opened and staff failed to discard the open vial with a date of 12/5/17 28 days after opening.

- Policy titled "Infection Management Program" reviewed on 1/8/18 at 3:333pm directed , open one muti-dose vial at a time, mark the vial with the date and time when opened.

- Observation in the supply storage room at 4:00pm revealed a gray container that contained six 3000cc bags of Glycine 1.5% irrigation fluid (used when performing urology procedures) with an expiration date of 1/1/18.

Administrative staff B interviewed on 1/8/18 at 4:00pm acknowledged the containers of Glycine had expired.