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A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined the Hosptial failed to ensure all medications were labeled after transfer from the original container as per policy. This was evident in 1 of 20 (Pt #1) clinical records reviewed.

Findings include:

1. The Hospital policy titled "Medication/Solution Pre-Procedure Set-Up" (last reviewed date of 9/22/11) was reviewed. The policy indicated "Procedure 1. Label medication(s) and/or solution(s) both on and off the sterile field even if only one medication/solution is to be used and medication or solution is transferred from the original packaging to another container... III. Label syringe or container with the drug name, strength, concentration...amount...expiration date..."

2. The clinical record of Pt #1 was reviewed. Pt#1 was born on 5/19/12 and had a circumcision performed on 5/20/12. The "Operative Report" indicated Pt #1 was consoled during the procedure with a small amount of Sucrose solution orally, and was inadvertently given Monsel Solution (0.1 - 0.2 ml) along with the Sucrose Solution. It was determined the baby received 0.1 - 0.2 ml of the dilute of Ferric Sulfate (Monsel's) and sucrose solution.

3. An interview per phone with the RN who administered the iron solution to Pt #1 was conducted on 7/10/12 at 1:00PM. The RN indicated she did not label the Monsel Solution (utilized to stop circumcision bleeding) after it was transferred from the multidose container to the medicine cup. "I drew it up (Monsel's solution) in the Sucrose solution syringe, did not look and recognized that I had given the baby a bit of it."

4. The above finding were verified with the Quality Manager, Director of Maternal/Child unit and the RN that administered the medication to the infant on 07/10/12 at 2:00 pm.