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Based on review of facility policies and procedures, medical records, patient interviews and staff interviews, the hospital's governing body failed to provide leadership and oversight for a safe setting by failing to ensure an organized nursing service with safe medication use practices, and by failing to ensure an effective Quality Assessment and Performance Improvement (QAPI) program providing development and implementation of initiatives to prevent recurrance of Sentinel Events.

Findings include:

A. The hospital failed to ensure an organized nursing service as evidenced by failing to ensure safe medication use practices.

~Cross refer to 482.23 Nursing Services, Condition Tag A0395

B. The hospital failed to have an effective Quality Assessment and Performance Improvement (QAPI) program by failing to ensure development and implementation of initiatives to prevent recurring Sentinel Events.

~Cross refer to 482.21 QAPI - Condition Tag A0263

Based on review of facility policies and procedures, medical records, patient interviews and staff interviews, the hospital failed to have an effective Quality Assessment and Performance Improvement (QAPI) program by failing to ensure development and implementation of initiatives to prevent recurring Sentinel Events.

Findings include:

The hospital's Quality Assurance and Performance Improvement (QAPI) program failed to ensure oversight of its patient safety processes by failing to ensure that the hospital's nursing staff completed remedial training and education to prevent potential patient medication administration errors.

~Cross refer to 482.21(e)(1) Executive Responsibilities (QAPI) - Standard Tag A0311

Based on review of facility policies and procedures, medical records, patient interviews and staff interviews, the hospital's Quality Assurance and Performance Improvement (QAPI) program failed to ensure oversight of its patient safety processes by failing to ensure that the hospital's nursing staff completed remedial training and education to prevent potential patient medication administration errors.

Findings include:

Review on 01/19/2011 of facility policy "Sentinel Event Investigation" dated 04/2009 revealed "A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof." Further review revealed "The action plan is implemented and results are monitored. Patient safety staff assigned will follow-up with those people responsible to implement action plans to assure tasks are completed..."

Review on 01/17/2012 of facility policy "High Risk Medication Verification Policy 1.1" dated 12/09 revealed "1. The following medications used in the Emergency Department are considered High Alert: A. Insulin (injectable and IV infusion)...2. Verification or double check of these high alert medications must be performed at the bedside...Verification or double checking...matches the 5 rights of medication administration: A. Right Patient, B. Right Medication..."

Review on 01/17/2012 of facility policy "Medication Administration Procedure" dated 01/09 revealed "1. Before a qualified nurse...administers medication, the following is verified:...B. The medication is verified as the correct medication...4) Check the medication label against the MAR (medication administration record) before preparing the med(ication) for administration..."

Closed record review for Patient #3 revealed a 49 year old female who presented to the facility's Emergency Department (ED) 11/14/2011 at 1956 with a complaint of difficulty breathing. Review of ED physician documentation "Emergency Department Report" dated 11/14/2011 revealed "EKG Interpretation: We did do an EKG out in triage which revealed normal sinus rhythm with a rate of 79...The patient's labs reveal...potassium low at 2.5...I gave potassium replacement 40 mEq (milliequivalents) p.o. (orally) and I ordered IV (intravenous) 10 mEq..." Review of ED nursing documentation revealed the potassium supplement medication K-Dur 40mEq was administered PO at 2301 with further documentation at 2301 "Potassium Chloride with lidocaine IVPB (IV piggyback) 10mEq...2347 Follow up: Response: No adverse reaction; IV Status: Infusion continued upon admit..." Review of the physician History & Physical (H&P) revealed the patient was admitted to the hospital for a large right-sided pleural effusion (fluid collection on the right lung), congestive heart failure, hypokalemia (low potassium), hypertension (high blood pressure) and gastroesophageal reflux disease. Review revealed the patient left the ED for transport to the PCCU inpatient area at 2344. Review of nursing documentation by the PCCU Registered Nurse (RN#3) at 0000 on 11/15/2012 revealed "pt (patient) arrived on unit via stretcher from the ED. pt transferred to bed. telemetry monitor placed on pt. pt HR (heart rate) 160, appears to be having a seizure, with whole body twitching noted and pt awake with eyes fixed and nonresponsive to voice commands. bp (blood pressure) 160/100, pt remains unresponsive. (Name of RN#1) called to verify pt baseline when entering ED. confirmed pt was walking and talking on arrival to ED. pt continue to be unresponsive to voice and painful stimuli. blood glucose checked at 0015 and found to be 7. 1 amp(ule) D50 (IV glucose) given ivp (IV push bolus). MD paged...0030 rechecked glucose, 191, pt more alert now but confused as to what is going on...EKG performed and pt is in Afib with RVR (atrial fibrillation with rapid ventricular response)..." Review of ED nursing documentation on the "Hand-Off Communication Report Admission-Transfer" revealed the form was completed at 2232 on 11/14/2011 (one hour and 28 minutes prior to the patient being received at the PCCU). Further review of the Hand-Off Communication form revealed the patient's vital signs at the time the form was completed were BP 129/84 with a pulse of 65. Review of PCCU nursing documentation on 11/15/2011 at 0100 revealed "pt starting to shake again and states, 'I am feeling so tired." glucose rechecked and found to be 26. 2nd amp D50 given. rechecked glucose at 0110 and is 149. at 0150 pt states 'I feel so tired and I want to go to sleep but I'm afraid to'...pt also noted to be shaking again. rechecked glucose and found to be 66...0200...decided to recheck a glucose and found it to be 31. 3rd amp of D50 given ivp. MD paged." Further review of PCCU RN documentation on 11/15/2011 at 0215 revealed "(Name of hospitalist) in to see pt and family. 0230 glucose...107. Cardiazem 10mg (milligram) bolus given and gtt (drip) started at 10ml/hr (ml per hour) for AFib with RVR..." Review of hospitalist documentation 11/15/2011 at 0215 revealed "Came to see pt (symbol for "secondary") to repeatedly low blood sugars. Pt on arrival to floor had BS (blood sugar) 7...on further discussion (symbol for "with") nursing, insulin was hanging & pt received 100 units insulin from ER (Emergency Room or ED). This had not been ordered. Potassium was supposed to be given to pt but received insulin instead. Review revealed the patient was transferred to a critical care unit of the hospital (CVRU) where she continued to receive a continuous infusion of intravenous glucose and additional D50 injections for low blood sugars (a total of 6 from 11/15/2011 at 0015 in the PCCU through 11/15/2011 at 0800 in the CVRU). Review of a cardiology consultation report dated 11/15/2011 revealed "...On presentation to the hospital, the patient had a blood pressure of 128/90s, heart rate of 105, and sinus tachycardia. Her potassium was low at 2.83. She was told her potassium would be replaced; however, she was given insulin instead in the ER, which dropped her glucose to 7. At that time she went into a new onset atrial fibrillation with rapid ventricular response and was started on a Cardiazem drip...Atrial fibrillation likely secondary to mismanagement of IV fluids as the patient was given insulin instead of potassium in the emergency department..." Review revealed the patient was discharged home 11/20/2012.

Review on 01/18/2012 of the facility's current census log revealed Patient #3 was a patient on the PCCU.

Interview with Patient #3 on 01/18/2012 at 1400 revealed the patient was readmitted to the facility for "drainage of fluid on her lungs". Interview revealed on 11/14/2011 the patient presented to the ED for difficulty breathing. Interview revealed the patient was alert and fully oriented when she presented to the ED for treatment. Interview revealed the patient was told her potassium was low and they would be giving her an IV infusion to replace the potassium. Interview revealed the patient observed her nurse come into the ED exam room and "hung a bag" and began the infusion then left the room. Interview revealed in 15-20 minutes she began to feel her heart race and had increasing shortness of breath. Interview revealed the patient had to "yell out" for help since the call light was still hung on the wall and out of reach. Interview revealed "when I couldn't reach the call light and no one responded when I called out, the only thing I knew to do was to take my fist and beat on the wall." Interview revealed "I must have passed out then (while beating on the wall), because the next thing I remember is waking up and my nurse on the floor (PCCU) was talking to me."

Interview on 01/18/2012 at 1430 with RN#1, the primary care RN in the ED for Patient #3 and Patient #1 on the evening of 11/14/201, revealed she had been a RN full time in the facility's ED for 5.5 years. Interview revealed on the evening of 11/14/2011 the RN was assigned to rooms 25-28 (each room had a patient in the room). Interview revealed Patient #3 was in room 27 and Patient #1 in room 28. Closed record review for Patient #1 revealed a 36 year old female who presented to the facility's ED 11/14/2011 at 1718 for a chief complaint of pain in buttocks and high blood sugars. Interview revealed there was an order to administer a 10mEq/100ml potassium infusion to Patient #3 and to initiate an insulin infusion (100 Units in 100 ml) for Patient #1. Interview revealed the RN went to the medication room and retrieved both of the medications. Interview revealed the RN went to each room and delivered the medications. Interview revealed "I hung what I thought was insulin (but was actually the potassium infusion) on (Patient #1) and programmed the pump for another nurse to check behind me." Interview revealed "I got (RN#2) to do the second check, but I guess all she did was check the pump settings and not what was hanging (in the IV bag)." Interview revealed the primary care RN then went to Patient #3's room and hung what she thought was a potassium infusion (but was the insulin infusion) and programmed the pump for an infusion rate of 100 ml/hr (milliliters per hour) which would infuse the 100 ml insulin bag containing 100 Units of insulin in one hour. Interview confirmed the insulin infusion was initiated at 2301 on 11/14/2011 at a rate of 100ml/hr on Patient #3, who was supposed to receive a potassium infusion. Interview revealed "I shouldn't have gotten both of the meds (insulin and potassium infusions) from the medication room at the same time." Further interview revealed "We (RN#1 and RN#2) should have checked the insulin drip together at the bedside and maybe we would have caught the mistake." Interview revealed nursing staff failed to follow facility policy by failing to perform a double check verification by two licensed staff at the bedside for the high risk medication insulin and failed to verify the correct medication was being administered to the correct patient.

Interview with administrative staff on 01/19/2012 at 1040 revealed a team met on the morning of 11/15/2011 to discuss the incident involving the wrong medications given to the wrong patients (#3 and #1). Interview revealed the meeting involved administrative, management and clinical staff (including RN #1 and RN#2). Interview revealed the flow of events were reviewed and the meeting found RN#1 failed to follow facility policy by retrieving medications for multiple patients at one time from the med room Interview revealed the staff further failed to follow facility policy when RN#1 and RN#2 failed to perform the double check for high risk medications by procedure and failed to perform the procedure together at the bedside. Interview revealed an action plan was developed and implemented 11/18/2011 after a Root Cause Analysis (RCA) was completed. Interview revealed the Director of Emergency Services was responsible for implementation and follow-up of action plan completion. Interview revealed both RN#1 and RN#2 were suspended three days without pay. Interview revealed RN#1 was a part-time weekend employee and for the week of 11/13/2011 was scheduled to work an eight hour shift 11/14/2011, and five additional 12 hour shifts from Tuesday 11/15/2011 through Saturday 11/19/2011. Review of a timekeeping record during the interview revealed RN#1 was suspended 11/15/2011, 11/16/2011 and 11/17/2011 and worked her regular Friday and Saturday 12 hour shifts. Interview revealed the action plan also included a remedial education plan for RN#1 and RN#2 to complete and developed by the North Carolina Board of Nursing. Interview revealed the education plan included completing a medication administration quiz and developing a poster regarding medication administration practices for review by all ED nursing staff by 02/17/2012. Interview revealed the remediation plan was voluntary for the staff to complete for the Board of Nursing but was made mandatory to complete for both of the nurses by the hospital. Interview revealed RN#2 had completed the plan (quiz and poster completed). Interview revealed RN#1 had completed the poster and had a deadline of 01/15/2012 to complete the quiz. Interview revealed RN#1 did not provide documentation the quiz was completed until 01/18/2012 (one day after survey entrance date). Interview revealed RN#1 was late completing the quiz due to "difficulties with logging into the system". Interview revealed the action plan developed from the RCA also included observation of RN#1 and RN#2 completing 10 medication passes, five of the medication passes to be high risk medications. Interview revealed RN#1 had not supplied documentation that she had completed the required number of medication passes which was not due until 01/31/2012. Review of the medication pass checkoff for RN#1 during the interview revealed the RN had completed two of the five high risk medication administration observations. Review a medication dispensing report revealed RN#1 had administered nine (9) other high risk medications during the time period from 11/18/2011, when the action plan was implemented until 01/14/2012. Interview revealed the nurse was responsible for finding someone to observe their administration of a high-risk medication. Interview revealed the observation could be by the manager, assistant manager or a pharmacist. Interview revealed any of these staff, with the exception of the manager, are available 24 hours a day 7 days a week. Interview failed to reveal an explanation why RN#1 had been able to complete the medication pass observations. Interview revealed all ED RN staff were to provide documentation of observation while administering 3 medications (including one pediatric and one high risk) by 02/17/2012. Interview revealed 40 percent (%) of the ED staff nurses had not yet completed the required medication pass observations on the date of interview. Interview revealed the ED staff were also required to document review of the posters created by RN#1 and RN#2 by 02/17/2012. Interview revealed only 58% of ED nursing staff had documented review of the posters on the date of interview. Interview revealed there had been insufficient oversight of the progress of RN#1 meeting the stated goals in the action plan by failing to complete the remediation education from the Board of Nursing by 01/15/2012. Further interview revealed ED staff had yet to complete the required observations and education on the date of interview.

Based on review of facility policies and procedures, medical records and patient and staff interviews, the hospital failed to ensure an organized nursing service as evidenced by failing to ensure safe medication use practices.

The findings include:

Facility nursing staff failed to follow facility policies and procedures regarding medication use for 2 of 2 records reviewed (#3, #1) resulting in an adverse event with Patient #3.

~cross refer to 482.23(c)(1) Administration of Drugs - Standard Tag A0405

Based on review of facility policies and procedures, medical records and patient and staff interviews, facility nursing staff failed to follow facility policies and procedures regarding medication use for 2 of 2 records reviewed (#3, #1) resulting in an adverse event with Patient #3.

Findings included:

Review on 01/17/2012 of facility policy "High Risk Medication Verification Policy 1.1" dated 12/09 revealed "1. The following medications used in the Emergency Department are considered High Alert: A. Insulin (injectable and IV infusion)...2. Verification or double check of these high alert medications must be performed at the bedside...Verification or double checking...matches the 5 rights of medication administration: A. Right Patient, B. Right Medication..."

Review on 01/17/2012 of facility policy "Medication Administration Procedure" dated 01/09 revealed "1. Before a qualified nurse...administers medication, the following is verified:...B. The medication is verified as the correct medication...4) Check the medication label against the MAR (medication administration record) before preparing the med(ication) for administration..."

1. Closed record review for Patient #3 revealed a 49 year old female who presented to the facility's Emergency Department (ED) 11/14/2011 at 1956 with a complaint of difficulty breathing. Review of ED physician documentation "Emergency Department Report" dated 11/14/2011 revealed "EKG Interpretation: We did do an EKG out in triage which revealed normal sinus rhythm with a rate of 79...The patient's labs reveal...potassium low at 2.5...I gave potassium replacement 40 mEq (milliequivalents) p.o. (orally) and I ordered IV (intravenous) 10 mEq..." Review of ED nursing documentation revealed the potassium supplement medication K-Dur 40mEq was administered PO at 2301 with further documentation at 2301 "Potassium Chloride with lidocaine IVPB (IV piggyback) 10mEq...2347 Follow up: Response: No adverse reaction; IV Status: Infusion continued upon admit..." Review of the physician History & Physical (H&P) revealed the patient was admitted to the hospital for a large right-sided pleural effusion (fluid collection on the right lung), congestive heart failure, hypokalemia (low potassium), hypertension (high blood pressure) and gastroesophageal reflux disease. Review revealed the patient left the ED for transport to the PCCU inpatient area at 2344. Review of nursing documentation by the PCCU Registered Nurse (RN#3) at 0000 on 11/15/2012 revealed "pt (patient) arrived on unit via stretcher from the ED. pt transferred to bed. telemetry monitor placed on pt. pt HR (heart rate) 160, appears to be having a seizure, with whole body twitching noted and pt awake with eyes fixed and nonresponsive to voice commands. bp (blood pressure) 160/100, pt remains unresponsive. (Name of RN#1) called to verify pt baseline when entering ED. confirmed pt was walking and talking on arrival to ED. pt continue to be unresponsive to voice and painful stimuli. blood glucose checked at 0015 and found to be 7. 1 amp(ule) D50 (IV glucose) given ivp (IV push bolus). MD paged...0030 rechecked glucose, 191, pt more alert now but confused as to what is going on...EKG performed and pt is in Afib with RVR (atrial fibrillation with rapid ventricular response)..." Review of ED nursing documentation on the "Hand-Off Communication Report Admission-Transfer" revealed the form was completed at 2232 on 11/14/2011 (one hour and 28 minutes prior to the patient being received at the PCCU). Further review of the Hand-Off Communication form revealed the patient's vital signs at the time the form was completed were BP 129/84 with a pulse of 65. Review of PCCU nursing documentation on 11/15/2011 at 0100 revealed "pt starting to shake again and states, 'I am feeling so tired." glucose rechecked and found to be 26. 2nd amp D50 given. rechecked glucose at 0110 and is 149. at 0150 pt states 'I feel so tired and I want to go to sleep but I'm afraid to'...pt also noted to be shaking again. rechecked glucose and found to be 66...0200...decided to recheck a glucose and found it to be 31. 3rd amp of D50 given ivp. MD paged." Further review of PCCU RN#3's documentation on 11/15/2011 at 0215 revealed "(Name of hospitalist) in to see pt and family. 0230 glucose...107. Cardiazem 10mg (milligram) bolus given and gtt (drip) started at 10ml/hr (ml per hour) for AFib with RVR..." Review of hospitalist documentation 11/15/2011 at 0215 revealed "Came to see pt (symbol for "secondary") to repeatedly low blood sugars. Pt on arrival to floor had BS (blood sugar) 7...on further discussion (symbol for "with") nursing, insulin was hanging & pt received 100 units insulin from ER (Emergency Room or ED). This had not been ordered. Potassium was supposed to be given to pt but received insulin instead. Review revealed the patient was transferred to a critical care unit of the hospital (CVRU) where she continued to receive a continuous infusion of intravenous glucose and additional D50 injections for low blood sugars (a total of 6 from 11/15/2011 at 0015 in the PCCU through 11/15/2011 at 0800 in the CVRU). Review of a cardiology consultation report dated 11/15/2011 revealed "...On presentation to the hospital, the patient had a blood pressure of 128/90s, heart rate of 105, and sinus tachycardia. Her potassium was low at 2.83. She was told her potassium would be replaced; however, she was given insulin instead in the ER, which dropped her glucose to 7. At that time she went into a new onset atrial fibrillation with rapid ventricular response and was started on a Cardiazem drip...Atrial fibrillation likely secondary to mismanagement of IV fluids as the patient was given insulin instead of potassium in the emergency department..." Review revealed the patient was discharged home 11/20/2012.

Review on 01/18/2012 of the facility's current census log revealed Patient #3 was a patient on the PCCU.

Interview with Patient #3 on 01/18/2012 at 1400 revealed the patient was readmitted to the facility for drainage of fluid on her lungs. Interview revealed on 11/14/2011 the patient presented to the ED for difficulty breathing. Interview revealed the patient was alert and fully oriented when she presented to the ED for treatment. Interview revealed the patient was told her potassium was low and they would be giving her an IV infusion to replace the potassium. Interview revealed the patient observed her nurse come into the ED exam room and "hung a bag" and began the infusion then left the room. Interview revealed in 15-20 minutes she began to feel her heart race and had increasing shortness of breath. Interview revealed the patient had to "yell out" for help since the call light was still hung on the wall and out of reach. Interview revealed "when I couldn't reach the call light and no one responded when I called out, the only thing I knew to do was to take my fist and beat on the wall." Interview revealed "I must have passed out then (while beating on the wall), because the next thing I remember is waking up and my nurse on the floor (PCCU) was talking to me."

2. Closed record review for Patient #1 revealed a 36 year old female who presented to the facility's ED 11/14/2011 at 1718 for a chief complaint of pain in buttocks and high blood sugars. Review of ED physician documentation dated 11/14/2011 revealed "The patient is a 36 year old female with a history of diabetes. She has been non-compliant with her insulin for the past year. The patient presents with general malaise...nauseous and weak...blood sugars have been running high...CO2 (consistent with diabetic ketoacidosis), glucose 425...The patient received insulin bolus followed by an insulin drip..." Review of ED nursing documentation dated 11/15/2011 at 2320 revealed "Novolin R 9 units/hr IV (insulin IV infusion)" and at 0045 Follow up: IV Status: Infusion continued upon admit." Review of nursing documentation by a RN in the SICU (surgical intensive care unit) on 11/15/2011 at 0122 revealed "Pt admitted to SICU room 1 via wheelchair. Assisted to bed..." Further review of SICU RN documentation revealed at 0153 on 11/15/2011 the patient's insulin gtt (drip) was infusing at 0 (zero) units/hr and was infusing at 18.2 Units/hr at 0300. Review revealed the patient was discharged home 11/21/2011.

Interview on 01/18/2012 at 1430 with RN#1, the primary care RN in the ED for Patient #3 and Patient #1 on the evening of 11/14/201, revealed she had been a RN full time in the facility's ED for 5.5 years. Interview revealed on the evening of 11/14/2011 the RN was assigned to rooms 25-28 (each room had a patient in the room). Interview revealed Patient #3 was in room 27 and Patient #1 in room 28. Interview revealed there was an order to administer a 10mEq/100ml potassium infusion to Patient #3 and to initiate an insulin infusion (100 Units in 100 ml) for Patient #1. Interview revealed the RN went to the medication room and retrieved both of the medications. Interview revealed the RN went to each room and delivered the medications. Interview revealed "I hung what I thought was insulin (but was actually the potassium infusion) on (Patient #1) and programmed the pump for another nurse to check behind me." Interview revealed "I got (RN#2) to do the second check, but I guess all she did was check the pump settings and not what was hanging (in the IV bag)." Interview revealed the primary care RN then went to Patient #3's room and hung what she thought was a potassium infusion (but was the insulin infusion) and programmed the pump for an infusion rate of 100 ml/hr (milliliters per hour) which would infuse the 100 ml insulin bag containing 100 Units of insulin in one hour. Interview confirmed the insulin infusion was initiated at 2301 on 11/14/2011 at a rate of 100ml/hr on Patient #3, who was supposed to receive a potassium infusion. Interview revealed "I shouldn't have gotten both of the meds (insulin and potassium infusions) from the medication room at the same time." Further interview revealed "We (RN#1 and RN#2) should have checked the insulin drip together at the bedside and maybe we would have caught the mistake." Interview revealed nursing staff failed to follow facility policy by failing to perform a double check verification by two licensed staff at the bedside for the high risk medication insulin and failed to verify the correct medication was being administered to the correct patient.

Interview on 01/18/2012 at 1615 with RN#3, the primary care RN for Patient #3 on the PCCU floor revealed the RN saw the patient roll by the nurses' station on the stretcher "and I immediately noticed she didn't look the same as what was documented on the report sheet from the ED." Interview revealed the report sheet from the ED documented the patient was alert and oriented, "the patient rolling by the nurses' station did not appear to be alert and oriented." Interview revealed "I got to the room as they were getting her in the bed. Her eyes were closed and she was twitching. I called the ED and spoke with (RN#1) and asked about the patient's status in the ED and she told me 'walking and talking'." Interview revealed "I wasn't able to arouse her so I called the charge nurse." Interview revealed other staff responded and a blood sugar was checked with a result of 7. Interview revealed the staff administered D50 and the patient responded within minutes but was confused, but alert. Interview revealed the patient soon after had another low blood sugar requiring treatment with D50 and the physician hospitalist was notified. Interview revealed "Our floor manager had also been contacted because we were concerned about why this was happening to the patient." Interview revealed the physician responded around 0200, and about the same time the floor manager called and asked if the patient had been given any medications in the ED. Interview revealed "I had unhooked an empty minibag from the primary line when the patient first got to the floor. I had assumed it was potassium since that was on the report sheet. I went to the room and turned the bag around to read the label and saw the bag contained insulin and not potassium." Interview revealed "We then realized the patient had received 100 Units of insulin over a one hour period." Interview revealed the patient was transferred to a higher acuity area for further monitoring and care.

Interview on 01/18/2012 at 1635 with RN#4, the primary care RN for Patient #1 in the SICU area revealed the patient arrived by wheelchair. Interview revealed "I could see the pump read 'insulin' but I couldn't see the label on the bag that was hanging." Interview revealed "I scanned the orders and reprogrammed the IV pump for the SICU location mode, since it was in ED mode when she arrived." Interview revealed "When I program a pump I always make it a habit to look at the label of what's hanging. When I turned the bag around, I realized what was infusing was the wrong med. I stopped the pump and called the hospitalist then I called the Pharmacy to get an insulin drip and filled out an incident report. I also notified my assistant manager because I was concerned another patient had gotten (Patient #1)'s insulin drip."

Interview with administrative staff on 01/19/2012 at 1040 revealed a team met on the morning of 11/15/2011 to discuss the incident involving the wrong medications given to the wrong patients (#3 and #1). Interview revealed the meeting involved administrative, management and clinical staff (including RN #1 and RN#2). Interview revealed the flow of events were reviewed and the meeting found RN#1 failed to follow facility policy by retrieving medications for multiple patients at one time from the med room Interview revealed the staff further failed to follow facility policy when RN#1 and RN#2 failed to perform the double check for high risk medications by procedure and failed to perform the procedure together at the bedside.

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