HospitalInspections.org

Based on the review of medical records, it was determined that in one of ten medical records, medical record # 4, the hospital failed to ensure that all drugs were administered in accordance with the orders of the practitioner. Findings:

Medical record # 4 contained the following hospitalist's order dated 02/10/10 timed 1635, "Morphine 1-2 mg IV Q 4 hours prn pain".

Documentation reflects that on three occasions Morphine was not administered according to the frequency identified in the physician's order dated 02/10/10.

The MAR dated/timed 02/10/2010 00:01:00 through 02/10/2010 24:00:00 reflects handwritten documentation of the following entry: "Morphine 1-2 mg IV Q 4 [hours] PRN Pain".
The handwritten entries documenting the times of the administration of Morphine on 02/10/10 are somewhat illegible. However, documentation reflects that Morphine was administered every 3 hours instead of every 4 hours as ordered by the physician. Documentation reflects Morphine 2 mg IV was administered at 2030 hours and at 2330 hours on 02/10/10.

The MAR dated/timed 02/11/2010 00:01:00 through 02/11/2010 24:00:00 reflects the same physician's order was incorporated into an electronically generated MAR with the following medication listed: "Morphine Sulfate 2 mg IV every 4 hrs PRN Pain (2 mg/ml carpujet) Dose 1-2 mg IV Q4 Hours PRN Pain". Documentation reflects that Morphine was administered every 3 hours instead of every 4 hours as ordered by the physician. Documentation reflects Morphine 1 mg was administered at 0230 hours and at 0530 hours on 02/11/10.

The MAR dated/timed 02/12/2010 00:01:00 through 02/12/2010 24:00:00 reflects an electronically generated MAR with the same medication listed: "Morphine Sulfate 2 mg IV every 4 hrs PRN Pain (2 mg/ml carpujet) Dose 1-2 mg IV Q4 Hours PRN Pain". Documentation reflects that Morphine was
administered every two hours instead of every 4 hours as ordered by the physician. Documentation reflects Morphine 1 mg was administered at 0920 hours and at 1140 hours on 02/12/10.


These findings also reflect noncompliance with the following Oregon Administrative Rule (OAR) for Hospitals:

OAR 333-510-0010(6) Patient Admission and Treatment Orders states, No medication or treatment shall be given except on the order of a licensed healthcare professional authorized to give such orders within the State of Oregon.