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The hospital's professional nursing staff failed to follow written policy and procedure related to medication administration resulting in two medication errors, one in the emergency department and one in nursing unit 2 East. The medication errors involved the same patient (Patient 309) and the same drug.

Refer to CFR 482.23(c) [A 404]

1. Based on observation, interview and record review, the professional nursing staff failed to adhere to nursing practice that was consistent with written hospital policy and procedure (#30035.99) related to medication administration for 4 of 41 sampled patients (103, 210, 211, 309). This resulted in two medication errors involving the same patient (Patient 309) and the same drug.

2. The hospital failed to ensure that medications were administered in accordance with the orders of the practitioner responsible for the patient's care. The Emergency Department record for Patient 103 had documentation that three medications were not administered until more than 1 1/2 hours after the orders. This resulted in the patient having severe pain for a longer period of time.

3. The hospital failed to ensure that the medication administration record accurately reflected the medication administration time.

Findings:

1. The Emergency Services [emergency department] report on 10/15/10 provided documentation that Patient 309 arrived at 10:37 AM with complaints of migraine headache, lower back pain, and abdominal pain. Subsequent evaluation by an Emergency Services Physician concluded that Patient 309 was to be treated for abdominal pain, pancreatitis (inflammation of the pancreas), and a urinary tract infection.

The documentation on the electronic medication administration record (eMAR) provided that the attending physician ordered a one-time dose of the narcotic Dilaudid for the control of pain. The documentation on the eMAR provided that a 1 milligram dose of Dilaudid was given via the IV route at 1:50 PM. This order was discontinued immediately after the administration on 10/15/10 per documentation in the medical record. Another one time order for 1 mg of Dilaudid via the IV route was obtained and given to Patient 309 for pain control at 4:18 PM.

The order for the Dilaudid was later renewed and amended on 10/15/10 at 6:16 PM to administer the medication via the IV route at 3 hour intervals, as needed. The medication dosage was to be adjusted for the pain severity based on the subjective assessment of Patient 309. The parameters of the Dilaudid order were documented as 0.4 mg for mild pain; 0.6 mg for moderate pain; 0.8 for severe pain.

RN C subsequently administered 1 mg of Dilaudid at 8:29 PM. This dose was inconsistent with the aforementioned physician order. RN C failed to give the correct prescribed dose of Dilaudid.

RN C was interviewed on 10/28/10 at 1:00 PM. RN C stated that he failed to view the order in its entirety prior to giving the narcotic because he did not "double click" on the Dilaudid order when viewing it on the eMAR.

The double click would have allowed RN C to see the order in its entirety (0.4 mg for mild pain; 0.6 mg for moderate pain; 0.8 for severe pain). RN C stated that when he read the initial order containing Dilaudid he "assumed" it was based on a previously phased out "pain protocol" which permitted a 1 mg dose of Dilaudid to be given based on the patient's perceived level of pain.

RN C's statement and actions were corroborated in a separate interview with the Emergency Department Nursing Director (EDNM) on 10/28/10 at 2:00 PM. The EDNM reiterated that RN C failed to verify the details of the entire narcotic order, and worked from the recently phased out standing orders, which provided the Dilaudid 1 mg as part of a protocol for the treatment of severe pain.

RN C failed to adhere to the hospital's written policy and procedure titled Medication Administration (#30035.99). Specifically RN C failed to ensure that the right dose was administered to Patient 309 as it was prescribed.

Patient 309 was subsequently admitted to the hospital's nursing unit 2 East just after midnight on 10/16/10. The admitting physician continued the Dilaudid pain medication with the same parameters of 0.4 mg for mild pain; 0.6 mg for moderate pain; 0.8 for severe pain.

Four different nurses became involved with the medication error that occurred on nursing unit 2 East. The hospital's administration consisting of the Regulatory and Quality Departments conducted an investigation into the incident/medication error. The hospital's investigation was corroborated by independent interviews conducted with the four nurses from unit 2 east on November 2 and 3, 2010 during the survey.

RN S was interviewed on 11/2/10 at 11:30 AM related to the incident on 10/16/10. RN S stated that she was caring for Patient 309. RN S stated that at approximately 2:45 AM on 10/16/10 Patient 309 requested pain medication and an assessment of the pain was completed.

RN S stated that when she went to verify/view the order on the eMAR she interpreted and read the order as 4 mg. of Dilaudid. The investigation by the hospital administration and CDPH both concluded that the order was correctly entered into the eMAR system at the time, and was confirmed to be "0.4 mg for mild pain; 0.6 mg for moderate pain; 0.8 for severe pain."

When RN S attempted to access the 4 mg dose of Dilaudid an alert was generated in the automated medication-dispensing machine. The term used by the hospital administration in the investigation related to the alert was "speed bump."

With this type of alert/speed bump it was necessary for RN S to call in another RN to verify the Dilaudid 4 mg dose in order to get the automated medication dispensing machine to release the Dilaudid. RN O provided the necessary steps (Biometric verification - fingerprint reader) in order to get the Dilaudid out of the medication-dispensing machine.

Both RN S and RN O failed to question the automated medication dispensing machine alert/speed bump element, thereby allowing the medication error to move forward.

RN S stated that the charge nurse notified her to attend to other urgent patient business. RN M offered to assist RN S with the administration of the 4 mg of Dilaudid to Patient 309. RN S stated that she handed the medication to RN M and went on to attend the other patient issue. Prior to this RN S already documented on the eMAR that the Dilaudid was administered to Patient 309. However, the dose was with RN M and had yet to be administered.

RN M was interviewed on 11/2/10 at 10:00 AM related to the incident on 10/16/10. RN M stated the Dilaudid 4 mg dose had already been pulled from the automated medication-dispensing machine and that the syringe was clearly marked with the medication and dose. RN M stated that he went to verify the dose and medication on the eMAR and looked at the dose box and saw that the 4 mg dose of Dilaudid medication was already charted as given by RN S. RN M stated that he failed to actually view the order for the Dilaudid.

RN G was interviewed on 11/3/10 at 8:00 AM related to the incident on 10/16/10. RN G stated that RN M approached her in a charting room and asked her to view the eMAR with him. RN G stated that both she and RN M viewed the eMAR, which contained the specific order for the Dilaudid. RN G went on to state that neither she nor RN M verified the order, but focused on the eMAR documentation that the 4-mg. dose of Dilaudid had already been charted as given.

The 4 mg dose of Dilaudid was documented as given at 2:50 AM, and with RN M stating that he had provided assistance to Patient 309 about "10 - 15 minutes" after the Dilaudid, helping her with bed positioning and beverage service.

According to the hospital administration's investigation Patient 309 was later found in bed unresponsive by RN S at approximately 4:10 AM. Emergency resuscitative (CPR) measures were employed and Patient 309 was transferred to an intensive care setting. On 10/18/10 Patient 309 expired.

The four RN's from 2 East failed to adhere to the hospital' s written policy and procedure titled Medication Administration (#30035.99). Specifically RN S,O,M, and G all failed to ensure that the right dose was administered to Patient 309 as it was prescribed, and when presented an opportunity to stop the medication error failed to verify the correct dose. Additionally, RN S charted medication prior to the administration of the medication, which was not consistent with the aforementioned policy.

2. While in the ED on November 2, 2010 at 10:23 A.M., Patient 103 had orders for Zofran (an anti-nausea medication) and intravenous fluids entered into the electronic medical record (EMR) at 10:10 A.M. Patient 103 also had orders for Dilaudid (a narcotic pain reliever) to be given intravenously (IV), entered into the EMR at 10:11 A.M.

Review of the eMAR at 11:00 A.M. showed that the medications had not yet been given.

When interviewed at 11:15 A.M., ED Nurse 10 stated she had an Intensive Care Unit (ICU) admission and another sick patient and that she was going to administer the medications to Patient 103 "now" (at 11:15 A.M.) She also stated that the charge nurse had been busy with another nurse's very ill patient and had not been available to assist her.

Later review of the eMAR showed that the medications and IV fluids were administered at 11:45 - 11:46 A.M.

Per review of Section III D in the policy, entitled Medication Administration dated 6/10, "all routine scheduled medications ...will be administered at the times specified on the Medication Administration Record and will be considered to have been properly administered if given within the time window of one hour before or one hour after the designated administration time."

3a. Patient 210 was admitted to the facility on 10/31/10, per the face sheet. According to the physician's orders and the electronic medication administration record (eMAR) reviewed on 11/2/10, the patient had current orders for 6 medications which were scheduled to be given at 9 A.M.

During an observation of a medication pass and review of the eMAR on 11/2/10, RN 209 withdrew the scheduled medications from the automated medication dispensing machine beginning at 9:25 A.M. At 9:26 A.M., the RN documented in the eMAR, prior to the administration of the medications, that she gave the medications at 9 A.M. The RN gave Patient 210 the 6 scheduled medications at 9:35 A.M.

Per the Policy and Procedure entitled, Medication Administration, dated 6/10, licensed nurses were to document medications after they were administered.

When interviewed on 11/2/10 at 9:40 A.M., RN 209 stated, "I charted the medications before I gave them." RN 209 also stated that the facility policy is to, "Document the meds (medications) after you give them."

b. Patient 211 was admitted to the facility on 10/7/10, according to the face sheet. Per the physician's orders and the eMAR reviewed on 11/2/10, Patient 211 had current orders for 12 medications scheduled to be given at 9 A.M.

During an observation of a medication pass and review of the eMAR on 11/2/10, RN 210 withdrew the scheduled medications from the automated medication dispensing machine beginning at 9:49 A.M. Between 9:50 A.M. and 9:57 A.M., RN 210 documented in the eMAR, prior to the administration of the medications, that she gave the medications at 10 A.M. The RN gave Patient 211 the 12 scheduled medications at 10:12 A.M.

Per the Policy and Procedure entitled, Medication Administration, dated 6/10, licensed nurses were to document medications after they were administered.

When interviewed on 11/2/10 at 10:18 A.M., RN 210 stated, "I charted I gave the medications at 10:00 before I gave them." She stated the policy was to document that the medications were given after they were administered.