HospitalInspections.org

Based on interviews and review of medical records, it was determined that the hospital failed to assure all drugs and medications were administered by a registered nurse in accordance with the orders of the practitioner responsible for the patient's care.

Findings include:

1. An interview with the Emergency Department (ED) Nurse Manager and Vice President of Patient Care Services on 11/08/2011 at approximately 0850 hours reflected their findings following a medication error caused by an ED RN (Employee #9) . The incident occurred during the care of a patient who presented emergently with a possible allergic reaction.

2. A medical record review of 1 out of 10 (patient #4) ED patients revealed the following: The patient was admitted emergently to the ED on 7/26/2011 with a possible allergic reaction. The patient was short of breath, had a swollen tongue and an "itchy red rash" over his arms and trunk. At 1800 hours the physician gave a verbal order for Epinephrine 0.5 mg sub Q. Employee #9 wrote the order on the "ER Physician Order Sheet" as "Epinephrine 0.5 mg sub Q" then administered the medication using an IV route. He/she documented giving Epinephrine 0.5 mg IV at 1800. Documentation at 1802 reflected he/she informed the physician that the Epinephrine was given IV. The physician's documented the patient's cardiac rhythm changed to "V-Tach X 2 min." The incident was documented on a Medication Safety Report form per policy.