HospitalInspections.org

Based on document review and interview, the facility staff failed to ensure the medication ordered for 1 of 3 patients, Patient #3, was reviewed for dosage accuracy when compared to home medications.

The findings include:

Patient #3's medical record was reviewed on 9/2/2020 and the following information was noted;

Patient #3 was admitted via the Emergency Department (ED) following a fall on 11/5/2018 and was diagnosed with hypotension, SIRS (Systemic Inflammatory Response Syndrome), H/O (History Of) Stem Cell Transplant and AKI (Acute Kidney Injury). Medications listed as prior to admission to the ED included Noxafil (posaconazole) 100 mg (milligrams) PO (by mouth) TBEC (tablet enteric coated) take 300 mg by mouth once a day. The Noxafil was also listed as medications pulled from a previous admission on 8/23/18.

Patient #3 was admitted inpatient on 11/5/2018. The Admitting Physician (Staff Member #10) was interviewed on 9/2/2020 at approximately 8:30 A.M. and stated, "I admitted the patient around 3:00 or 4:00 A.M. I was on duty until about 7:00 A.M. and never saw [Patient #3] again. I never looked at the record but tried to order the medications [Patient #3] was taking at home. Some medications auto-substitute through the pharmacy. When you try to order through EPIC (electronic medical record) what the patient is taking at home, an alert will pop up and tells you what you can order in the medication's place. Sometimes, there is only one option.

To my knowledge, there is no way to override the system. The only other option is to allow the patient to use their medications brought in from home. We are discouraged from allowing the use of home medications.

When I went to order the Noxafil 100 mg PO TBEC, take 300 mg by mouth once a day, the system would only let me order 400 mg oral suspension twice a day. That was my only choice. That is what I ordered.

I guess calling the pharmacist would have been an alterative.

This has happened with other medications such as Symbicort."

On 9/1/2020 at approximately 11:50 A.M., the Pharmacy Clinical Coordinator (Staff Member #16) was interviewed regarding the ordering and prescribing of Noxafil for Patient #3. Staff Member #3 stated, "At the time the prescriber was ordering [Patient #3's] medication (Noxafil), EPIC would only allow the order to be placed as 400 mg oral suspension twice a day. There was no way to override what EPIC displayed. The prescriber (Staff Member #10) was given the option to order as EPIC listed or to cancel. The prescriber never called the pharmacy. This was an EPIC malfunction. We had to escalate the issue to EPIC and the end result was to just get rid of the alternative alert.

The most serious side effect from Noxafil is potential liver failure. [Patient #3] was receiving the delayed release tablets at home and received the oral suspension while here. Yes, [Patient #3] received the wrong dose of medication which was being given as a prophylaxis dose. Delayed release medications enter the body more slowly than oral suspensions. An oral suspension is gobbled up by the body more quickly."

A screen shot of EPIC provided by Staff Member #16 and email attached, dated 1/10/19, documented the following:
If a prescriber went into the facility's preference list in EPIC and tried to order posaconazole tablets an alert would fire.
The alert documentation provided by Staff Member #16 stated the following:
***RESTRICTION***
Per the [Name of Facility] P&T Committee, Posaconazole (Noxafil) has been restricted to use by Infectious Disease physicians for:
***Exception Continue therapy for patients on posaconazole PTA***
1 Prophylaxis of invasive Aspergillus and Candida infections
DR (delayed release) tablets: 300 mg twice daily x 1 day (loading) then 300 mg daily
Suspension: 200 mg (5 ml (milliliters) three times daily (no loading dose)
2 Oropharyngeal Candidiasis
Suspension 100 mg twice daily (loading), then 100 mg daily x 13 days
3 Oropharyngeal Candidiasis Refractory to Intraconazole and or Fluconazole
Suspension 400 mg (10 ml) twice daily

Notes by Staff Member #16 stated, "When a prescriber orders posaconazole from the home medication list to continue, the alert below fires - it only allows one option - 400 mg BID (twice a day) which is the treatment dose for refractory oral candidiasis and on option to continue with 300 mg daily for prophylaxis.
Additionally, once the order is opened, it hard stops the provider to select the desired P&T approved indication - BUT- also has preselected at the bottom of the order, "Refractory Oropharyngeal Candidiasis" - this allows for the prescriber to select a different indication at the top of the order that is selected at the bottom of the order --- which leads to confusion."

Emails dated January 16, 2019 provided by Staff Member #16 document "...The dose error was discovered by an outside insurance audit [Name of insurance provider] and we have to report back to them about corrective actions..."

On 9/2/2020 at approximately 8:00 A.M. an interview was conducted with the Director of Information Technology (Staff Member #9) who stated, "Alterative alerts, such as the one the provider received, assist the pharmacy in managing their inventory. This alert was expanded for use during medication reconciliation on admission. I do not know when it was expanded to the work flow (order panels physicians would use to order medications).

What we discovered when this incident occurred was EPIC code does not allow order panels to be displayed with the physician converts home medications to inpatient medications. We worked with the EPIC vendors and told them of our concerns. EPIC has message boards and we could see other providers were having the same problems. My opinion is EPIC offered a work around rather than fix the problem. We needed the problem fixed but they pushed the work around's. We discovered we had other medications with similar alerts so we reconfigured all of them. We had twenty (20) to thirty (30) other medications with this problem. This had the potential to be a real problem if it occurred with another drug.

Yes, the physician could have called the pharmacy, canceled the order and started from scratch without the panel or could have edited the order before signing it."

Patient #3 received the incorrect dose of Noxafil 400 mg twice a day on November 5, 6, 7, 8, 9, 10, 11 and 12, 2018.

Based on observations, interviews and documents reviewed, the facility staff failed to ensure they arranged seating in the Emergency Department (ED) waiting area and the main hospital waiting area in such a manner to encourage patients, visitors and family to be six (6) feet apart to aid in decreasing the spread of COVID-19. There were approximately eight (8) people in the ED waiting area during the observation time of 2:30 P.M.

The findings include;

On 8/31/2020 at approximately 2:30 P.M. the ED waiting area was observed. The chairs utilized by patients and their family member(s) were placed arm next to arm with every other chair being turned in the opposite direction or turned to face the wall. The seat base of most of the chairs was approximately twenty-four (24) inches wide. There were some bariatric chairs available for use. There was an area just off the main ED waiting area where patients could also sit if the main ED waiting area became to busy. This area did not have have any turned chairs and chairs were arm and arm with each other.

The nurse performing triage was observed cleaning the triage chairs between patient use. The chairs used for waiting were not observed cleaned between patient use.

Staff Member #6 was interviewed during the observations of the ED regarding the cleaning of chairs in the waiting area and stated, "I just hired a person this week to make sure the chairs are cleaned between patient or visitor use."

The chairs in the main lobby were observed on 8/31/2020 at approximately 1:30 P.M. and again on 9/1/2020 at approximately 9:45 A.M. During both observations there was one empty chair between each used chair. The distance between chairs was approximately twenty-four (24) to thirty (30) inches. There were people sitting in the lobby.
Staff Member #1 stated, "I see what you mean. We will have to configure a different sitting area."

The facility provided a document titled: Procedures: IP&C Emerging Pathogens 201
Located in the Infection Control Manual with an Original Date: 3/5/2003 and a Revision Date: 6/2/2020.
Page 7 Pandemic Management; Source Control documented: "When appropriate and possible, control waiting areas by allowing options for patients to wait in the personal vehicle, outside the building (unless weather does not permit), or in waiting areas with chairs configured at least 6 feet apart or arranged back to back or other configurations where patients face away from one another..."

The CDC (Centers for Disease Control and Prevention)
Your Health; Personal and Social Activities Updated Sept. 11, 2020 documents the following:
What you need to know
· Stay home if sick.
· Wear masks in public settings and when around people who don't live in your household, especially when other social distancing measures are difficult to maintain.
...Use social distancing (stay at least 6 feet away from others)...