HospitalInspections.org

Based on document review and interview, the facility failed to provide care in a safe setting by not ensuring the intended dose of medication was ordered for 1 of 10 patient medical records reviewed. (P1)

Findings include:

1. The facility policy titled, "Patient/Parent Rights and Responsibilities, Complaints and Grievances", no policy number, publication date 06/22/2023, indicated patient's have the right to receive appropriate and compassionate care at all times.

2. The facility policy titled, "Medication Administration and Management", no policy number, publication date 05/08/2023, indicated it is the provider's responsibility to communicate complete information when ordering medications. Elements of a complete medication order include dose of medication.

3. Medical Record review for P1 indicated on 8/16/23 an order for IVIG (Intravenous Immune Globulin) 15 gm (grams) was ordered to be given to the patient by MD1 (Medical Doctor). On 8/16/23 at 8:44 am the patient received one dose of 15 gm (grams) IVPB (Intravenous Piggyback) of Immune Globulin (IVIG) NF-Gammunex-C [Immune Globulin (Human) Caprylate/Chromatography].

4. Grievance documentation dated 9/1/23 indicated MD1 spoke with the P1's parent to relay it was his/her intent to give the patient 5 gm of IVIG, MD1 inadvertently entered 15 gm by mistake on the order set, and the patient did experience side effects and was subsequently hospitalized post infusion from 8/17/23-8/20/23. On 9/5/23 risk management staff spoke to pharmacy staff which confirmed the dose of 15 gm of IVIG was within normal dose range according to the P1's documented weight, but was not MD1's intended dose for the patient. On 9/12/23 risk management confirmed that a medication error occurred since 5 gm was the intended dose, not the ordered dose of 15 gm.

5. In an interview on 3/11/24 at approximately 3:05 pm with A7 (Director of Pharmacy) confirmed P1 had a documented weight in the system at the time of order entry, there is a wide range of dosing for IVIG, no flags would have fired for pharmacy for the ordered 15 gm amount ordered for the patient based on weight based dosing of IVIG, and common side effects of IVIG are consistent with the patient's at the time of admission to H1 on 8/17/23