HospitalInspections.org

Based on interviews and documentation review, it was determined the Hospital had not (yet) completed 2 actions items called for by its Internal Investigation of Neonate #1's SRE/medication administration error.

Findings included:

A review of the Hospital Internal Investigation related to Neonate #1's SRE/medication administration error revealed it called for:
> Immediate identification banding of neonates with pre-registration information (until bracelets with birth information are available).
> Investigation of the possibility of decreasing the timeframe of availability of post-birth identification bracelets.
> Immediate cessation of the practice of bringing Terbutaline, oxytocin and/or other maternal medications into delivery rooms "just in case"/without a physician order.
> Immediate cessation of the practice of bringing neonatal medications into delivery rooms prior to birth.
> Placement of a second mobile computer with scanner in the labor & delivery room when delivery is imminent.
> Immediate and strict adherence to BMV policies/procedures.
> Formal re-education and counseling of Staff RN #1 regarding medication administration.
> Development of a Quality Monitoring Plan related to the neonatal medication administration process and Staff RN #1's medication administration practices.
> A RCA.
> A survey of medication administration practices throughout (all areas of) the Hospital.

A review of the implementation of the Corrective Action Plan associated with the Hospital Internal Investigation related to Neonate #1's SRE/medication administration error revealed all action items had been addressed except for the RCA and the Hospital-wide survey of medication administration practices.

At Exit Conference on 1/13/11, the Hospital-System Senior Vice President/Chief Nursing Officer said a RCA Team had been identified and a RCA meeting was in the process of being scheduled, and a plan for the Hospital-wide survey of medication administration practices was in the development phase.