HospitalInspections.org

See A-0405.

Based on staff interviews, clinical record review and review of hospital policies and procedures the hospital failed to ensure that Licensed Staff F followed physician's orders to give Epinephrine, (a life-saving medication used to treat allergic reactions), intramuscular (IM, an injection into the muscle), and gave the epinephrine to Patient 1 intravenously (into the vein), which resulted in Patient 1 developing a severe headache and cerebral hemorrhage, (bleeding into the brain) which required surgery.

Findings:

Patient 1, a 15 year old male was admitted to the Emergency Department on 2/1/16 at 10:30 p.m.with rash, itching, nasal congestion, and a tingling sensation in his throat, (symptoms of a life threatening allergic reaction), after using a new body wash.

Review of the Emergency Records, dated 2/1/16 for Patient 1 indicated the following medications were ordered by Physician A to treat an allergic reaction; 1. Solumedrol 125mg. (anti-inflammatroy which reduces swelling), one time IV (intravenously); 2. Benadryl 50 mg. one time IV; (an antihistamine used to treat allergy); 3. Pepcid 20 mg. IV one time, (can be used as an antihistamine in conjunction with benadryl); 4. Epinephrine, (used to ease breathing by opening airways and narrows the blood vessels to maintain blood pressure), 1:1000 dilution 300 mcg (0.3mg) IM (Intramuscular) one time.

During an interview on 2/10/16 at 1 p.m., Licensed Nurse F stated she was working evening shift, (3 p.m. - 11:30 p.m.) in the Emergency Department on 2/1/16. She stated her assignment included being medication nurse for the Rapid Care Clinic (located within the emergency department, routinely staffed by two physicians and two technicians). She was informed by the technician that there were medications to be given to Patient 1, so after reviewing Physician A's new orders, she retrieved the medications from the Pyxis, (an automated medication dispensing system). She stated the first three medications, (Solumedrol, Pepcid and Benadryl) were ordered IV, and the Epinephrine was ordered IM. She gave the first three medications IV and decided to have the Epinephrine dose double checked by another nurse, (Licensed Staff G) due to Patient 1's age of 15. Licensed Nurse G double checked the Epinephrine dose, observed Licensed Nurse F draw up the medication in a 3 cc syringe, confirming it was the correct dose. Licensed Nurse F went into the room to give the medication while Licensed Nurse G
signed out the medication on the electronic medication Administration Record, (MAR).

Licensed Nurse F stated when Licensed Nurse G asked her what was the site for the medication, Licensed Nurse F realized she had given the Epinephrine IV, not IM. She stated she immediately notified Physician A.

Licensed Nurse F stated she had intended to give the Epinephrine IM as ordered and she was unclear why she had given it IV.

During an interview on 2/11/16 at 3 p.m., Licensed Nurse G stated she was the Triage Nurse, (Triage RN does initial assessment and screening of patients to prioritize their treatment), the evening shift on 2/1/16. She was going on her break when Licensed Nurse F asked her to double check the dose of Epinephrine for Patient 1. Licensed Nurse G stated she double checked the dose, and watched Licensed Nurse F draw up the Epinephrine in a 3 cc syringe. She stated the dose was correct. She then went out of the room to document on the electronic MAR while Licensed Nurse F went to give the Epinephrine to Patient 1. When Licensed Nurse F was coming out of the room after giving the medication Licensed Nurse G asked Licensed Nurse F what was the site so she could document it. Licensed Nurse F said she had given it IV, instead of IM. Licensed Staff G stated Physician A was immediately notified. Licensed Nurse G stated she did not observe Licensed Nurse F give the Epinephrine.

Review of the Emergency Department record for Patient 1 indicated that all the medications were given at 11:13 p.m. Further review indicated at 11:15 p.m., Patient 1 complained of a headache, his blood pressure increased to 145/75, (blood pressure on admit was 129/74), his heart rate increased from 94 to 116.

During an interview on 2/22/16 at 9 a.m., Physician A stated she saw Patient 1 in the Rapid Care Clinic the evening of 2/1/16 for an allergic reaction to a body wash Patient 1 had used. She stated she ordered medications to be given and the plan was after the medications were given she would move him over to the regular emergency department to be observed.

She stated when she was informed by Licensed Nurse F that the Epinephrine had been given IV instead of IM, and Patient 1 was complaining of a severe headache, she spoke with Physician B, informing him of what happened. Patient 1 was immediately moved over to the regular Emergency Department under the care of Physician B.

During an interview on 2/22/16 at 12 p.m., Physician B stated Patient 1 was transferred to his care at 11:25 pm., on 2/1/16. He stated Patient 1 was holding his head and complaining of a bad headache. Patient 1 was alert and oriented and all his neurological checks were within normal limits. Physician B stated quite frequently patients can have a headache after receiving Epinephrine. Physician B stated he ordered Morphine 2 mg. to be given to Patient 1 for the headache. He stated Patient 1 went to sleep shortly afterward.

At 1:30 a.m., Patient 1 woke up, stated his headache was better, his rash was resolved and even though he was sleepy from the medications he wanted to go home. Physician B stated he felt Patient 1 was stable and discharged him to home with his father. Discharge medications included Benadryl 25mg casules to take by mouth every 4-6 hrs as needed for allergy symptoms; 2. Pepcid 1 tablet by mouth two times per day. 3. Prednisone (an anti-inflammatory medication) 20mg tab, take three tablets by mouth daily for 5 days.

Patient 1 was discharged to home around 1:45 a.m. on 2/2/16.

Additional chart review indicated Patient 1 returned to the Emergency Department at 7 a.m., on 2/2/16 with a severe headache, 9 out of 10 on the pain scale, (used to measure severity of pain on a scale of 1-10 with 10 being the worst pain) He also complained of nausea.

Review of the physician's notes dated 2/2/16 at 8 a.m., indicated Patient 1 was moaning in pain. A Cat Scan ( CT)( an x-ray test which the computer generates cross-section views with detailed images of internal organs) of the head was ordered to rule out cerebral bleeding. The CT results revealed a cerebral hemorrhage, (bleeding in the brain).

Patient 1 was transferred to a higher level of care and required immediate surgery to correct the hemorrhage.

During interviews on 2/11/16 and 2/22/16, Pharmacist E stated Physician A's order for the Epinephrine 1:1000 0.3 mg IM was correct and had been reviewed by the pharmacist prior to it being given. She stated since the Epinephrine was an appropriate dose for IM injection there was no "High Alert" warning on the Pyxis, but as an added safety measure the route "intramuscular" was written in tall man, (upper case) letters. Review of the Mar, Administration Detail revealed route "intraMUSCULAR" for the Epinephrine.

Epinephrine given intravenously can have an adverse reaction of cerebral hemorrhage, stroke and heart irregularities. The preferred route for Epinephrine is by subcutaneous or intramuscular injection except in cases of cardiac arrest or anaphylactic shock. Lippencott 8th Edition IV Drug Handbook, published 2004, pages 310 - 311. Lippincott-Nursing2009 Drug Handbook; Pages 844-847.

Institute for Safe Medication Practices Canada, Volume 14-Issue 4, April 16, 2014; Alert: Wrong Route Incidents with Epinephrine - states if Epinephrine 1mg/1ml 1:1000 dilution is erroneously given intravenously in situations where subcutaneous, (an injection under the skin), or intramuscular administration is indicated severe harm such as cardiac arrythmias, cerebral vascular hemorrhage or death can occur.

Review of Hospital policy titled Medication Administration, last reviewed/approved 10/2015, indicated personnel who administer medications will follow medication practices in order to ensure patient safety, including following the Eight Rights of Safe Medication Administration; Right patient; Right Medication; Right dose; Right route; Right Time; Right documentation; Right reason; Right response.