HospitalInspections.org

Based on interview and clinical record review, the hospital failed to ensure pharmacy monitoring and oversight of scheduled medication in the ED (Emergency Department). This failure had the potential to cause the incorrect dosing of patients and/or the diversion of medications to go un-noted.

Findings:

On 7/11/12 at 9:10 AM, during the discussion with the Director of Pharmacy (DPH) regarding oversight of the scheduled medications in the ED pyxis (automatic dispensing cabinet), a list of scheduled medications removed by staff from the ED pyxis was requested for review for the period between 7/7/12 and 7/8/12. Review of the medication list provided by the DPH revealed numerous narcotic medications including morphine, hydromorphone and fentanyl, etc. were removed for patients receiving pain treatment in the ED.

The clinical records for Patient 19 and Patient 20 were concurrently reviewed with the DPH on 7/11/12. The clinical record for Patient 19 indicated that on 7/7/12 at 3 AM and again at 3:20 PM, 6 milligrams (mg) of morphine were ordered to be administered via intravenous (IV) push. Review of the pyxis records for Patient 19 indicated 8 mg of morphine were removed for each of those times. The clinical record for Patient 20 indicated that on 7/7/12 at 8:30 PM, hydromorphone 1 mg IV was ordered and 2 mg of the medication was removed from the ED pyxis. There was no record of any wastage of morphine and hydromorphone by staff for each of these two patients.

In the interview with the DPH on 7/11/12 at 10:53 AM, she acknowledged that any excess narcotic medications that were not administered to patients would need to be wasted and documented during the medication removal process. During the discussion with the DPH and Pharmacist (Pharm) 1 they were asked to provide documented evidence that the hospital has revised processes to reduce access to medication prior to pharmacy reviews and to allow the pharmacy department to have the ability to review medications in the ED and to provide oversight in accordance to their plan of correction.

Review of the information provided by Pharm 1 on 7/11/12 revealed the hospital had started reviewing for ED medication orders on 6/25/12 and currently about one out of every ten ED patients was chosen for review according to Pharm 1. In addition, no review of withdrawal of the scheduled medications by a pharmacist to determine whether the dose ordered by the prescriber and the dose removed from the ADC (Automatic Dispensing Cabinet) and administered to patients were the same. This process provided no oversight and accountability that narcotics and other addictive and potent medications were given as prescribed. Medication adverse events would not be identified and could potentially place patients at risk of receiving inappropriate medications leading to serious harm and injury.