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Based on record review, physician and staff interview, a medication error occurred for one of one Patient's hospitalized in January 2010. The medication Calcitriol was administered incorrectly over a six day duration without detection by the Attending Physician/Hospitalist.

The findings are as follow:

The Patient, a 91 year old female was admitted to the Hospital for a complaint of shortness of breath. Diagnoses included a history of kidney cancer with removal of one kidney (date unknown).

Review of the Emergency Department (ED) Triage Nurse documentation in the Historical Section for Home Medications dated 01/05/10 indicated that the Patient had been prescribed the medication Calcitriol 0.25 micrograms by mouth, taken three times a week. However, the ED Triage misspelled the medication as Calatriol. The ED Triage Nurse indicated the Patient had also taken the medication Allopurinol. There was no documented frequency nor notation when the medications were last taken by the Patient.

The Director of Risk Management said the ED nursing staff did not always document the dosage and frequency of medications because it may not be known. The Director of Risk Management and the Director of Quality Management said the physicians were responsible for the medication reconciliation at the time of admission to the Hospital.

Review of the Hospital Policy for Medication Reconciliation indicated medication reconciliation was to occur when medication orders were written on admission, at the time of discharge and communicated to the next provider of service whether within or outside of the organization. The Philosophy for the implementation of the Policy was the development, reconciliation and communication of an accurate medication list throughout the continuum of care; essential in the reduction of transition-related adverse drug events. The Hospital's Process indicated patients and/or families were to be asked to complete the Home Medication List in the ED and/or at the time of admission.

There was no specific medication list documented in the Patient's record which clearly identified either the Patient and/or a family member contributed to or provided the current medications taken by the Patient in the ED. The Hospital's Policy indicated the practitioner (Registered Nurse, Nurse Practitioner, Certified Registered Nurse Anesthetist and/or Physician's Assistant) would review the list with the patient and/or family. The practitioner was to sign, time and date the list. The Policy indicated the admitting physician reviewed the Home Medication List and referenced the list in order to complete the Admission Medication History and Order Form.

Review of the Patient's Admission Medication History and Orders Form dated 01/05/10 indicated the Resident Physician documented he reviewed the Patient's home medications and he reconciled the individual drug names, dosage and frequency. The Resident Physician ordered to continue the medication Calcitriol. However, the Resident Physician documented the order as Calcitriol 0.25 milligrams (instead of micrograms) by mouth three times a day (TID). The Resident Physician signed and dated the Admission Medication History and Order Form and he indicated his source for medication reconciliation was both the Patient and family and previous discharge paperwork. It was not specifically clear if the discharge paperwork was the Podiatry After Visit Summary dated 12/30/09. The Source of Medication Section on the Admission Medication History and Order Form did not identify the on-line EPIC electronic medical record available to the medical staff as a reference source.

The Resident Physician said he reviewed the Patient's medications taken at home with both the Patient and a family member. The Resident Physician said he also reviewed the on-line EPIC electronic medical record for the list of home medications. The Resident Physician said he did not review the ED record because the list and the ED record were not often completed at the time of the patient's admission. The Resident Physician said the EPIC record had the correct dosage and frequency of the Patient's medication Calcitriol. The Patient's EPIC record was not maintained in the Patient's medical record.

Continued review of the Patient's medical record indicated the Resident Physician reviewed the Patient's medications daily which included the Calcitriol ordered three times a day.

Hospitalist #1 said the resident discussed the Patient's medications but he did not review the Admission Medication History and Order Form/ Reconciliation List nor was there evidence the Hospitalist counter signed the Admission History and Order Form. Hospitalist #1 said the Patient should have been administered Calcitriol 0.25 micrograms by mouth three times a week not three times a day. Hospitalist #1 said Calcitriol was not administered more than twice a day.

There was no documented diagnosis to justify the need for Calcitriol three times a day.

Review of the Medication Administration Record (MAR) indicated the nursing staff administered the Calcitriol 0.25 micrograms by mouth three times a day for the duration of her hospitalization.

There was no documented evidence the Patient had any negative outcomes from the medication error.

Based on record review, physician and staff interview, a medication error occurred for one of one Patient's hospitalized in January 2010. A Resident Physician failed to accurately reconcile the medication Calcitriol taken by the Patient prior to admission for correct dosage and frequency of administration. There were inconsistencies in reconciling the same medication in the Transfer Summary sent to a skilled nursing facility on the day of the Patient's discharge.

The findings are as follow:

Review of the ED Triage Nurse documentation in the Historical Section for Home Medications on 01/05/10 indicated that the Patient had been prescribed the medication Calcitriol 0.25 micrograms by mouth, taken three times a week. However, the ED Triage Nurse misspelled the medication as Calatriol. The ED Triage Nurse indicated the Patient had also taken the medication Allopurinol. There was no documented frequency nor notation when the medications were last taken by the Patient.

Review of the Hospital Policy for Medication Reconciliation indicated medication reconciliation was to occur when medication orders were written on admission, at the time of discharge and communicated to the next provider of service whether within or outside of the organization. The Philosophy for the implementation of the Policy was the development, reconciliation and communication of an accurate medication list throughout the continuum of care; essential in the reduction of transition-related adverse drug events. The Hospital's Process indicated patients and/or families were to be asked to complete the Home Medication List in the ED and/or at the time of admission.

Review of the Patient's Admission Medication History and Orders Form dated 01/05/10 indicated the Resident Physician documented he reviewed the Patient's home medications and he reconciled the individual drug names, dosage and frequency. The Resident Physician ordered to continue the medication Calcitriol. However, the Resident Physician documented the order as Calcitriol 0.25 milligrams (instead of micrograms) by mouth three times a day (TID). The Resident Physician signed and dated the Admission Medication History and Order Form and he indicated his source for medication reconciliation was both the Patient and family and previous discharge paperwork. It was not specifically clear if the discharge paperwork was the Podiatry After Visit Summary dated 12/30/09. The Source of Medication Section on the Admission Medication History and Order Form did not identify the on-line EPIC electronic medical record available to the medical staff as a reference source.

The Resident Physician said he reviewed the Patient's medications taken at home with both the Patient and a family member. The Resident Physician said he also reviewed the on-line EPIC electronic medical record for the list of home medications. The Resident Physician said he did not review the ED record because the list and the ED record were not often completed at the time of the patient's admission. The Resident Physician said the EPIC record had the correct dosage and frequency of the Patient's medication Calcitriol. The Patient's EPIC record was not maintained in the Patient's medical record.

Continued review of the Patient's medical record indicated the Resident Physician reviewed the Patient's medications daily which included the Calcitriol ordered three times a day.

Hospitalist #1 said the resident discussed the Patient's medications but he did not review the Admission Medication History and Order Form/ Reconciliation List nor was there evidence the Hospitalist counter signed the Admission History and Order Form. Hospitalist #1 said the Patient should have been administered Calcitriol 0.25 micrograms by mouth three times a week not three times a day. Hospitalist #1 said Calcitriol was not administered more than twice a day.

There was no documented diagnosis to justify the need for Calcitriol three times a day.

Continued review of the Patient's medical record indicated the Resident Physician reviewed the Patient's medications daily including the medication Calcitriol 0.25 micrograms taken three times a day by mouth.

Review of the Discharge Medication List from the Physician and Nurse dated 01/09/10 indicated the reconciled home medication Calcitriol was misspelled as Cac/leitrool 0.25 milligrams to be taken two/three times a day. The Resident entered scratch marks both in the drug name and frequency to be taken. There was no signature that a registered nurse reconciled the Patient's medications with a physician at the time of discharge as per Policy.

The Discharge RN said she did not reconcile the Patient's medications on Discharge and transfer to a skilled nursing facility.

The same Discharge/Transfer Summary dated 01/09/10 listed the Patient's medication prescribed prior to admission as Calcitriol 0.25 milligrams by mouth taken as twice a day. Again, the medication dosage and frequency were incorrect. The Discharge/Transfer Summary listed the discharge medication as Calcitriol 2.5 milligrams by mouth three times a day. The Calcitriol was not supplied in milligrams but rather in micrograms.

Continued review indicated an Addendum Discharge/Transfer Summary was prepared by Hospitalist #2 on 01/11/10. Hospitalist #2 indicated the Discharge Medication list recommended the medication Calcitriol 0.25 milligrams by mouth three times a day.

Based on record review, physician and staff interview, a medication error occurred for one of one Patient's hospitalized in January 2010. A Resident Physician failed to accurately reconcile the medication Calcitriol taken prior to admission for correct dosage and frequency of administration There were inconsistencies in reconciling the same medication in the Discharge Transfer Summary sent to a skilled nursing facility on the day of the Patient's discharge.

The findings are as follow:

Review of the ED Triage Nurse documentation in the Historical Section for Home Medications on 01/05/10 indicated that the Patient had been prescribed the medication Calcitriol 0.25 micrograms by mouth, taken three times a week. However, the ED Triage Nurse misspelled the medication as Calatriol. The ED Triage Nurse indicated the Patient had also taken the medication Allopurinol. There was no documented frequency nor notation when the medications were last taken by the Patient.

Review of the Hospital Policy for Medication Reconciliation indicated medication reconciliation was to occur when medication orders were written on admission, at the time of discharge and communicated to the next provider of service whether within or outside of the organization. The Philosophy for the implementation of the Policy was the development, reconciliation and communication of an accurate medication list throughout the continuum of care; essential in the reduction of transition-related adverse drug events. The Hospital's Process indicated patients and/or families were to be asked to complete the Home Medication List in the ED and/or at the time of admission.

Review of the Patient's Admission Medication History and Orders Form dated 01/05/10 indicated the Resident Physician documented he reviewed the Patient's home medications and he reconciled the individual drug names, dosage and frequency. The Resident Physician ordered to continue the medication Calcitriol. However, the Resident Physician documented the order as Calcitriol 0.25 milligrams (instead of micrograms) by mouth three times a day (TID). The Resident Physician signed and dated the Admission Medication History and Order Form and he indicated his source for medication reconciliation was both the Patient and family and previous discharge paperwork. It was not specifically clear if the discharge paperwork was the Podiatry After Visit Summary dated 12/30/09. The Source of Medication Section on the Admission Medication History and Order Form did not identify the on-line EPIC electronic medical record available to the medical staff as a reference source.

The Resident Physician said he reviewed the Patient's medications taken at home with both the Patient and a family member. The Resident Physician said he also reviewed the on-line EPIC electronic medical record for the list of home medications. The Resident Physician said he did not review the ED record because the list and the ED record were not often completed at the time of the patient's admission. The Resident Physician said the EPIC record had the correct dosage and frequency of the Patient's medication Calcitriol. The Patient's EPIC record was not maintained in the Patient's medical record.

Continued review of the Patient's medical record indicated the Resident Physician reviewed the Patient's medications daily which included the Calcitriol ordered three times a day.

Hospitalist #1 said the resident discussed the Patient's medications but he did not review the Admission Medication History and Order Form/ Reconciliation List nor was there evidence the Hospitalist counter signed the Admission History and Order Form. Hospitalist #1 said the Patient should have been administered Calcitriol 0.25 micrograms by mouth three times a week not three times a day. Hospitalist #1 said Calcitriol was not administered more than twice a day.

There was no documented diagnosis to justify the need for Calcitriol three times a day.

Review of the Discharge Medication List from the Physician and Nurse dated 01/09/10 indicated the reconciled home medication Calcitriol was misspelled as Cac/leitrool 0.25 milligrams was to be taken two/three times a day. The Resident entered scratch marks both in the drug name and frequency to be taken. There was no signature that a registered nurse reconciled the Patient's medications with a physician at the time of discharge as per Policy.

The Discharge RN said she did not reconcile the Patient's medications on Discharge and transfer to a skilled nursing facility.

The same Discharge/Transfer Summary dated 01/09/10 listed the Patient's medication prescribed prior to admission as Calcitriol 0.25 milligrams by mouth taken as twice a day. Again, the medication dosage and frequency were incorrect. The Discharge/Transfer Summary listed the discharge medication as Calcitriol 2.5 milligrams by mouth three times a day. The Calcitriol was not supplied in milligrams but rather in micrograms.

Continued review indicated an Addendum Discharge/Transfer Summary was prepared by Hospitalist #2 on 01/11/10. Hospitalist #2 indicated the Discharge Medication list recommended the medication Calcitriol 0.25 milligrams by mouth three times a day.

Although Hospitalist #2 authenticated the Patient's Discharge/Transfer Summary on 01/11/10 prior to the the Patient's Transfer. The incorrect dosing was not detected. There was no evidence Hospitalist #2 reviewed the Discharge Medication List from the Physician and the Nurse which evidenced a misspelling of the drug name Calcitriol and a second entry written over the frequency for the medication.

Based on record review, physician and staff interview, the Pharmacist failed to recognize an incorrect acronym for the dosaging for one of one medications ordered for the Patient in January 2010.

The findings are as follow:

Review of the Patient's Admission Medication History and Orders Form dated 01/05/10 indicated the Resident Physician documented he reviewed the Patient's home medications and he reconciled the individual drug names, dosage and frequency. The Resident Physician ordered to continue the medication Calcitriol. However, the Resident Physician documented the order as Calcitriol 0.25 milligrams (instead of micrograms) by mouth three times a day (TID). The Resident Physician signed and dated the Admission Medication History and Order Form and he indicated his source for medication reconciliation was both the Patient and family and previous discharge paperwork. It was not specifically clear if the discharge paperwork was the Podiatry After Visit Summary dated 12/30/09. The Source of Medication Section on the Admission Medication History and Order Form did not identify the on-line EPIC electronic medical record available to the medical staff as a reference source.


The Pharmacist reviewed the Patient's Admission Medication History and Order Form and entered into the Patient's profile Calcitriol 0.25 micrograms by mouth three times a day.

The Pharmacist did not contact the ordering physician nor notify the Hospitalist for the incorrect acronym used in the prescribing of the medication Calcitriol.

The Pharmacist said the medication can be ordered up to 2 micrograms in 24 hours. However, there was no clear documentation for the justification and need for the medication found in the Patient's medical record.

Hospitalist #1 said the medication Calcitriol was give up to twice a day.

Review of the ED Triage Nurse documentation for the Historical Section for Home Medications indicated the Patient had taken Calcitriol 0.25 micrograms (misspelled as Calatriol)by mouth three times a week.

The Pharmacy continued to dispense the medication Calcitriol 0.25 micrograms three times a day for the Patient in the automated dispensing machine.

Review of the Medication Administration Record indicated the Patient was administered Calcitriol 0.25 micrograms by mouth three times a day during her six day hospitalization.