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Based on review of one, (Pt#1) of ten medical records, and review of Hospital policies and procedures related to the administration of medications, the Hospital failed to ensure that Patient #1 received an appropriate dose of Dobutamine and that the medication Dobutamine was recorded in Patient #1's medical record. Review of the Hospital's policy/procedure regarding medication administration was not consistent with acceptable standards of practice.

Findings include:

Review of Patient #1's medical record indicated the Attending Cardiologist ordered Dobutamine 2.5 ?g/kilogram (kg)/minute (min) on 12/20/11 at 10:20 A.M. The Hospital lists "?g" as an unacceptable abbreviation for microgram.

Nurse #1 was interviewed on 2/6/12 at 11:15 A.M. She said the unit of measure looked like mg, not ?g, for Dobutamine. Nurse #1 did not recognize that her interpretation of the order would result in a dose which would be many times the usual starting dose. She acknowledged that she did not follow through on her concerns about the dobutamine dose with another nurse or the prescriber.

The interpretation was compounded when Nurse #1 used a generic dosing conversion table to calculate the infusion rate. Rather than choosing the calculated dose/minute as prescribed, she chose the dose/hour.

A concurrent order for Dopamine clearly used the appropriate abbreviation, mcg.

Nurse #1 said she had not used Dobutamine and Dopamine together and felt that was an unusual order. Nurse #1 said she frequently works with the Attending Cardiologist and had complete confidence in him. Nurse #1 said she began both medications.

Review of Patient #1's electronic medication administration record (e-MAR) dated 12/20/11, did not indicate that Nurse #1 had documented the administration of either Dobutamine or Dopamine.

Review of the Hospital policy and procedure related to the administration of medications did not indicate that the administration of medications must be documented in the medical record as established in acceptable standard of nursing practice.

Review of the medical progress note dated 12/20/11 at 10:50 P.M. indicated that a Dobutamine dosing error was identified and corrected on the subsequent shift. The patient received a much higher dose than intended. Had this error not been recognized and corrected by the oncoming nurse, serious sequallae would have resulted.