HospitalInspections.org

Based on document review, interview, and review of hospital policies and procedures, the hospital failed to follow its policies involving discrepancies in controlled substances accounting.
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Failure to resolve discrepancies in controlled substances accountability risks medication errors and potential drug diversion.
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Findings:
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1. The hospital's policy and procedure titled "Medication Distribution: Pyxis Medication Discrepancy" (Reviewed 01/2015) read in part: The medstation has a 'Document Discrepancy' function in the main menu to prompt the users to document and resolve any discrepancies discovered during the transaction. . .While every effort should be made to resolve the discrepancy immediately, the charge nurse is responsible for running a discrepancy report and resolving all discrepancies by the end of his/her shift. If the charge nurse is unable to resolve the discrepancy, the pharmacy may be contacted to provide assistance or additional reports. All discrepancies must be resolved in 7 days. . .All unresolved discrepancies or irregularities shall be described and recorded by using he Patient Safety Net online reporting system (PSN)."
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2. The hospital's policy and procedure titled "Controlled Substances: Discrepancies and Loss Reporting" (Reviewed 03/2015) read in part: "A discrepancy is created whenever controlled substance inventory quantities do not match the quantities in documentation systems (either automated counts or manual logs). . . 1. All unresolved controlled substance discrepancies shall be documented via the Patient Safety Net on-line medication event reporting system. 2. All unresolved controlled substance discrepancies shall be reported immediately to the pharmacy manager for their area."
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3. On 2/2/2016 at 10:00 AM, Surveyor #1 reviewed the hospital discrepancy report with pyxis pharmacist (Staff Member #1). Surveyor #1 observed there were two clinical areas (8 East Medicine and OR East MB) with discrepancies that exceeded 19 and 14 days respectively. In an interview with Staff Member #1 at the time of the document review, s/he confirmed that they had contacted the clinical area leadership but had been unable to resolve the discrepancy and had not filed a PSN as of yet.
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4. On 2/2/2016 at 11:45 AM, Surveyor #1 requested the incident reports for the 8E-MED and OR-EAST-MB/2.3 from the medication safety pharmacist (Staff Member #2) for review. Staff Member #2 was unable to locate a PSN report for either clinical area.
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5. On 2/2/2016 at 2:30 PM, Surveyor #1 interviewed the nurse manager (Staff Member #3) about the unresolved controlled substance discrepancy. Staff Member #3 confirmed that s/he was aware of the discrepancy and was in contact with the staff member involved who was a part time employee. The nurse manager acknowledged that there was no PSN report filed at the time of survey as required by hospital policy.

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Based on record review and review of hospital policies and procedures, the hospital failed to ensure that hospital staff conducted monthly inspections of all drug storage areas to prevent administration of outdated medications as required.
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Failure to assure medication storage areas are devoid of outdated or otherwise unusable medications puts patient at risk for receiving medications with compromised sterility, integrity, or stability.
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Findings:
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1. The hospital's policy and procedures titled "Medication Distribution: Inspection of Areas Containing Medications" (Reviewed 10/2015) read in part: "All areas of the Medical Center containing medications will be inspected monthly. . . The inspection will be completed and documented on Medication Quality Assurance for Medication Units/Clinic Inspections Form. This inspection will be marked on the Unit Inspection log document."
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2. On 2/2/2016 at 9:30 AM, Surveyor #1 reviewed the monthly medication unit inspection reports and found no documentation to indicate the pharmacy staff had completed monthly inspections for seven units (5WA, 5WB, 4W, 3WA, 2WA, 2WB, and 2WC) in the west hospital for the month of November.
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