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Based on interviews and record review, the hospital failed to ensure heparin (a high-alert medication, to thin the blood) was given as per the hospital established protocol (formal set of rules and procedures to be followed during a particular course of treatment) for one of two patients (Patient 32) receiving heparin infusion. The failure resulted a medication error, and had the potential for adverse effects such as bleeding for the patient.

Findings:

The hospital's policy and procedures, "Medication Safety: High Alert Medications," dated 5/2019, indicated intravenous heparin as one of its "high-alert" medications- those "that are likely to contribute to medication errors."

The hospital's policy and procedures, "Weight Based Heparin Dosing and Monitoring", dated 3/2019, allowed for the pharmacist to make recommendations for heparin doses and rate changes along with appropriate laboratory monitoring, using the hospital's established Adult Weight-Based Heparin Protocol. Each indication on the protocol had a different set of established procedures, which included the bolus dose (large dose of substance given by injection for the purpose of rapidly achieving a needed therapeutic concentration in the bloodstream), the initial infusion rate, and adjustment rates based on the patient's laboratory value obtained during heparin treatment.

On 10/17/19 at 2:50 p.m., a concurrent interview and review of Patient 32's medical record with Pharmacist A and registered nurse supervisor B (RNS B) indicated Patient 32 was admitted to the hospital with diagnoses including pulmonary embolism (blockage in one of the pulmonary arteries in the lungs). While in the Emergency Department (ED), he had a physician order, dated 10/12/19, for heparin infusion to be given per the Cardiac Protocol Order Set (procedures for patients with heart problems). Patient 32 weighed 70 kilograms (kg, unit of measurement) during this visit. According to the Cardiac Protocol, the maximum bolus amount of heparin was 4,000 units.

The pharmacy heparin monitoring record indicated, on 10/12/19 at 7 p.m., the pharmacist changed the physician's order from the Cardiac Protocol to Pulmonary Embolism (PE) Protocol (based on the patient's diagnosed indication). Per the PE Protocol, the bolus amount was 80 units/kg x patient's weight. Thus, for Patient 32, the bolus amount was 80 units/kg x 70 kg = 5,600 units. The pharmacist made the recommendation to increase the ordered bolus dose from 4,000 units to 5,600 units (difference of 1,600 units), and communicated this change with an ED nursing staff, who documented this communication at midnight on 10/12/19.

The medication administration record indicated the ED staff administered a heparin bolus dose of 4,000 units on 10/12/19 at 11:23 p.m. Approximately an hour later, on 10/13/19 at 00:21 a.m., another ED nursing staff gave an additional bolus amount of 2,800 units, more than the amount recommended by the pharmacist. The pharmacy heparin monitoring record indicated, "Bolus dose (round to nearest 100 units): 4,000 units + 2800 units = 6,800 units > 5,600 units. Spoke to [ED nurse's name] to give 1,600, not 2800 units."

The Nurse's Notes, on 10/13/19 at 2:16 p.m., confirmed this error. It indicated, "...pt received 4000 units heparin bolus on 10/12/19 at 2323 AND 2800 units heparin bolus on 10/13/19 at 0021 in ER. Per [pharmacist's name], she explained to ER charge nurse that for treatment for PE, bolus should be 5600 units heparin. However pt received another 2800 units heparin bolus in ER..."

During an interview on 10/18/19 at 8:42 a.m., Pharmacist A and RNS B confirmed the heparin bolus for Patient 32 was not given per the hospital's established protocol. Pharmacist A said it was a medication administration error which was already reported through the hospital medication error reporting system.

Based on observation and interview, the facility failed to ensure the medication Lidocaine was stored in proper conditions and was available for patient use. This practice increased the risk of patients receiving less effective medications during treatment at the facility.

Findings:

Review of the hospital's policy, "Medication Storage", dated October 2019, indicated, "...Medications shall be stored in proper conditions of sanitation, temperature, safety and security. Temperature and ventilation in the work areas will maintain medications ..."

During an observation on 10/16/2019 at 10:45 a.m., in the Anesthesia work room, three 10cc vials of Lidocaine were noted to be on top of paper surgical supplies by the door, in a room not monitored for temperature and humidity.

During a concurrent interview with the Director of Surgical Services, he confirmed the medications were stored inappropriately and removed them from the patient care area.

Based on observation and interview, the facility failed to ensure all expired supplies were removed from the surgical patient care area. This practice increased the risk of patients receiving care with expired and ineffective supplies.

Findings:

During an observation on 10/16/2019 at 10:45 a.m., in operating room six, one container of Sani-cloths (Disinfectant wipes) was noted to have expired 7/20/2018. During a concurrent interview with the Director of Surgical Services, he confirmed the Sani-cloths were expired and he removed them from the patient care area.

During an observation on 10/16/2019 at 10:55 a.m., in the sterile back hallway, one Proximate linear cutter reload 55 mm (additional surgical staples for a surgical device) was noted to have expired on 9/2018. During a concurrent interview with the director of surgical services, he confirmed the cutter reload package was expired and he removed it from the surgical supply area.

During an observation on 10/16/2019 at 10:55 a.m., in the sterile hallway suture room, five 2-0 Vicryl (Sterile thread used during surgery) suture packages were noted to have expired 1/20/2019. During a concurrent interview with the Director of Surgical Services, he confirmed the sutures were expired and he removed them from the surgical supply area.

Review of the hospital's policy, "Accounting for Expired and Damaged Goods", dated 1/2017, indicated "Purpose. To ensure expired and/or damaged supplies are not received, distributed or available within the facility for utilization ..."

Based on observation and interview, the facility failed to maintain a sanitary and dust free environment in the Post Anesthesia Care Unit (PACU). This practice increased the risk of surgical site infections for surgical patients.

Findings:

During an observation on 10/16/2019 at 10:25 a.m., in the PACU Bay 6, a thick coating of dust was noted on the top of the patient vitals monitor. During a concurrent interview with the Director of Surgical Services, he acknowledged the finding.

Review of the hospital's policy, "Environmental Services", dated 4/2017, indicated "...Daily Cleaning ...Damp Clean- Use germicidal solution and clean cloth and thoroughly clean surfaces and designated equipment ..."