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Based on a review of policies, procedures, 11 patient records other documentation, it is revealed that patient #10 received two doses of Phenobarbital resulting in adverse reactions.

Patient #12 was an elder female with a cognitive developmental disability who following a fall in which she was wearing a helmet, presented to the emergency department (ED) on 12/18/2014 at 1836. Despite the helmet, patient #12 had received a laceration to her forehead. Patient #12 had a medical history inclusive of seizure disorder.

No acute brain pathology was found related to the fall. However, patient #12 was found to have a fever. Subsequent blood work revealed a WBC of 17.0, and a Phenobarbital level of 23.8 (norm 15-40 mcg/ml). Patient #12 was admitted to rule out sepsis on 12/19 at 0156.

Pharmacy Medication Reconciliation Policy (revised 10/14) stated in part, "The Pharmacy will collect, verify and document the home medication list for patients admitted through the emergency department .... " Pharmacy hours were listed in the policy as 0800-midnight Sunday - Saturday.

Review of the "Patient Care Manual" for "Medication Reconciliation" revealed:

"a. For all patients treated in the ED - There will be a complete list of home medications collected including name, dose, route, & frequency ....A list will be collected as soon as feasible at the conclusion of the situation." The list is expected to be completed within 12 hours, and physician reconciled within 24 hours.

The hospital had a medication list provided by the sending facility which included "Phenobarbital 1 gr (grain) BID (twice a day)." From this list, and found in other documentation, an error occurred when a medication technician was gathering information for the medication reconciliation process. Consequently, a medication order was written by a PA (Physician Assistant) for Phenobarbital 1000 mg BID, which over the course of the two doses patient #10 received, was approximately 30 times greater than the dose patient #12 had taken previously.

Patient #12 received 1 gram of Phenobarbital twice on the first day of admission at 0813 and again at 2011. This caused patient #12 to become very lethargic and her Phenobarbital levels to rise to 59.7 where norms are 15-40 micrograms/milliliter. When this error was corrected following the two doses, patient #12's Phenobarbital was discontinued until her levels became therapeutic once again.

Patient #12 was administered two other anti-seizure medications during this time, and no seizure activity was noted. On 12/25, the level was down to 28.6 micrograms/milliliter. Patient #12 recovered and she was restarted on a Phenobarbital dose of 60 mg twice a day which was equivalent to her original dose.

Survey of Pharmacy processes revealed appropriate and safe processes. The hospital identified the error, and took steps to prevent their recurrence. However, in this case, the hospital failed to recognize that the patient's medications at the ICF ID facility was in grains and not grams.