HospitalInspections.org

1. Based on reviews of policies and procedures, grievance reports, and personal interviews Methodist Hospital failed to follow established protocol addressing complaints/grievances.
The findings included:
a. Following a review of the hospitals policies and procedures for conducting a grievance/complaint investigation with staff members #2 and #4 on 4/11/13 in the hospital's conference room revealed a medication error occurred one day prior to the patient being transferred to another hospital on 2/12/13. According to the complainant she reported the error to the nursing staff and hospital administrators on 2/11/13 at 3:00 a.m. and she had not receive any correspondence from Methodist Hospital since her son's discharge and transfer on 2/12/13. Staff member #1 acknowledged she could not provide evidence of compliance with the requirements as required by regulations.
b. A review of the hospital's own investigation conducted on 4/11/13 in the conference room with staff members # 2 and # 4 revealed administrators had indeed conducted an investigation and root cause analysis had been performed following the patient's transfer to another hospital. Staff member # 1 acknowledged immediate changes were made both before and after the root cause analysis was done and there are still measures being implemented by the pharmacy 60 plus days following the incident however she could not provide evidence anyone from Methodist Hospital had contacted the complainant and informed her of the outcome of their investigation as required by policy and regulations.
c. Interviews conducted with staff members # 2 and # 4 revealed they assumed the grievance was resolved because the complainant spoke with the patient's physician and administrators following the incident. Yet they could not provide evidence the measures taken to conduct the investigation and resolutions were ever made known to the complainant. An interview with the complainant as of 4/22/13 revealed she still has not received any correspondence from the hospital.

1. Based on medical records reviews, patient safety and pharmacy policies and procedures, and personal interviews Methodist Hospital failed to administer medications as ordered by the medical staff.
The findings included:
a. A review of the medical record conducted on 4/9/13-4/10/13 revealed the patient had physician orders to receive glycopyrrolate (robinul) 0.8 mg every eight hours per tube written on 2/1/13 at 17:10 p.m. .The patient continued to receive the medication in this manner thru his feeding tube until 2/11/13 at 03:00 a.m. when a member of the nursing staff gave the medication in an injectable form via the patient's intravenous line. The medication error was reported to the staff by the patient's mother.
b. A review of the medication error with members of the hospital staff conducted on 4/11/13 revealed the medication error may have occurred because the barcode used to acquire the medication is the same for requesting the suspension form of the medication as is the injectable form used for intravenous administration.
c. Interviews with hospital pharmacy staff conducted on 4/11/13 revealed the nature of the medication error did not negatively affect the patient but did not follow the route of administration specified by the physician. Changes to prevent further incidents with robinul had been implemented and a wider review of similar medications was still being reviewed to include changes for individual barcodes for specific routes of administration.