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Based on review of patient records, review of hospital policy, and staff interview, the hospital failed to ensure that all staff followed approved policies and procedures related to the administration of medications to patients for 2 of 8 patient records reviewed (Patients #1 and #2).

Failure to implement performance improvement actions on known drug administration system issues risked patient health and safety.

Findings:

The following policies related to medication administration were reviewed:
1. The patient care policy, "Administration of Medication (#8720.5480 dated 2/2009) under item 12 read, "A valid range order will include a minimum and maximum dose and a maximum frequency."
2. The Pharmacy Department policy, "Medication Orders (#7170.5422 dated 11/08) under item 12 regarding "Titrate Orders-(orders to increase or decrease a drug dose based upon patient response such as morphine drips...") read, "...A valid order includes an initial starting dose, criteria for and amount of incremental increases or decreases, and a maximum dose OR specify 'no limit or no maximum dose' when appropriate."

Patient #1-Record review evidenced this patient was admitted on 3/1/2010 in respiratory failure. After determining that palliative comfort care was desired by the patient and family, a physician wrote the following order: "Morphine 1 mg (milligram) IV continuously (after) 2 mg IV bolus. Titrate for comfort and respiratory distress."

There was no specific range, no incremental increases identified, and no maximum dose or 'no limit' specified in the written order as required by hospital mandated pharmacy and patient care procedures.

Pharmacy filled the order without contacting the physician for clarification, and nursing administered the medication without contacting the physician for required parameters of drug management.

Review of the nurses notes evidenced that the morphine drip was initiated at 2 mg/hr and was increased to 60 mg/hr in less than 3 hours. Documentation of the patient's symptoms did not include pain assessments, and only brief descriptions of respiratory effort and heart rate. For example, at 1300 on 3/1/2010 a nursing progress note read, "Face cyanotic. Continues to be (rapid breathing). Morphine drip increased to 20 mg/hr." One and one-half hours later the rate was increased to 50 mg/hr.

Staff interviews on 5/18 and 19/2010 confirmed that in palliative or comfort care the amounts, rate and increases of the medication administered to Patient #1 were within normal limits to meet patient comfort needs. Staff agreed that the written order lacked required information for an acceptable range, and maximum dose (or 'no limit') to be in compliance with approved policy and procedure.

In staff interviews on 5/18 and 19/2010 with nursing, pharmacy and administrative staff, it was acknowledged that not all physicians wrote palliative orders in accordance with approved policies, and that pharmacy and nursing staff did not consistently ask for clarification prior to medication administration to the patient.

A similar example was observed for Patient #2.

The hospital failed to ensure that all departments followed approved policies and procedures related to medication administration to all patients.

Based on review of patient records, review of hospital policy, and staff interview, the hospital failed to ensure that all staff followed approved policies and procedures related to the administration of medications to patients for 2 of 8 patient records reviewed (Patients #1 and #2).

Failure to implement hospital approved policy and procedure for the safe administration of medication to all patients risked patient health and safety.

Findings:

The following policies related to medication administration were reviewed:
1. The patient care policy, "Administration of Medication (#8720.5480 dated 2/2009) under item 12 read, "A valid range order will include a minimum and maximum dose and a maximum frequency."
2. The Pharmacy Department policy, "Medication Orders (#7170.5422 dated 11/08) under item 12 regarding "Titrate Orders-(orders to increase or decrease a drug dose based upon patient response such as morphine drips...") read, "...A valid order includes an initial starting dose, criteria for and amount of incremental increases or decreases, and a maximum dose OR specify 'no limit or no maximum dose' when appropriate."

Patient #1-Record review evidenced this patient was admitted on 3/1/2010 in respiratory failure. After determining that palliative comfort care was desired by the patient and family, a physician wrote the following order: "Morphine 1 mg (milligram) IV continuously (after) 2 mg IV bolus. Titrate for comfort and respiratory distress."

There was no specific range, no incremental increases identified, and no maximum dose or 'no limit' specified in the written order as required by hospital mandated pharmacy and patient care procedures.

Pharmacy filled the order without contacting the physician for clarification, and nursing administered the medication without contacting the physician for required parameters of drug management.

Review of the nurses notes evidenced that the morphine drip was initiated at 2 mg/hr and was increased to 60 mg/hr in less than 3 hours. Documentation of the patient's symptoms did not include pain assessments, and only brief descriptions of respiratory effort and heart rate. For example, at 1300 on 3/1/2010 a nursing progress note read, "Face cyanotic. Continues to be (rapid breathing). Morphine drip increased to 20 mg/hr." One and one-half hours later the rate was increased to 50 mg/hr.

Staff interviews on 5/18 and 19/2010 confirmed that in palliative or comfort care the amounts, rate and increases of the medication administered to Patient #1 were within normal limits to meet patient comfort needs. Staff agreed that the written order lacked required information for an acceptable range, and maximum dose (or 'no limit') to be in compliance with approved policy and procedure.

In staff interviews on 5/18 and 19/2010 with nursing, pharmacy and administrative staff, it was acknowledged that not all physicians wrote palliative orders in accordance with approved policies, and that pharmacy and nursing staff did not consistently ask for clarification prior to medication administration to the patient.

A similar example was observed for Patient #2.

The hospital failed to ensure that all departments followed approved policies and procedures related to medication administration to all patients.