HospitalInspections.org

The facility failed to ensure the nursing staff safely administered medication as specified by facility policy.

Findings include:

1. Review of P1 medical records indicated that on 10/25/2019 an order was placed for a lactated ringers to be run at 100 milliliters per hour (mL/hr). At 2324 hours on 10/25/2019, staff registered nurse (RN1) initiated the infusion of fentanyl 2500 micrograms (mcg) in 250 milliliters (mL's) 0.9 sodium chloride at 100 mL's per hour for 61 minutes. Total infusion was 1,119.4 mcg. There were active orders for fentanyl, but the medicine was off at the time as a "sedation vacation."

2. Review of F1 incident report, indicated F1 staff registered nurse (RN1) failed to follow the policy specified "Seven Rights of Medication Administration." By scanning the wrong pump channel, RN1 administered the incorrect medication, incorrect dose, and failed to administer the correct medication in its entirety. RN1 failed to correctly utilize the "Alaris IV Medication Safety system and EPIC electronic record system, by incorrectly interpreting electronic alert messaging that warned of the error.

3. On 9/28/2020 at 1000 hours, S2, Chief Quality, Regulatory, and Patient Safety, confirmed that (RN 1) did in fact deliver a bolus of 1,119.4 micrograms (mcg) of Fentanyl in error on 10/25/2019 at 2324 hours through 10/26/2019 at 0033 hours.