HospitalInspections.org

Based on medical record review and review of hospital policy and procedure, facility staff failed to document the amount of intravenous Benadryl administered to Patient Identifier (PI #1) on the patient's Medication Administration Record (MAR) seven of nine times from January 13, 2010 through January 17, 2010.

This deficient practice of incomplete documentation, effected PI # 1, one of ten sampled patients, and has the potential to result in a medication error.

Findings include:

1. Medical Record:

According to the History and Physical dated January 10, 2010:
PI # 1 was admitted to the hospital on January 10, 2010 with a history of Chronic Obstructive Pulmonary Disease (COPD). Her PCO2 increased to 140 and the patient became "somnolent and confused. "PI # 1 " was placed on BIPAP (Bi -level Positive Airway Pressure) in the Emergency Room and there was some improvement." The physician documented the patient is "anxious and has a cough. She is on BIPAP at home." The chest X-ray showed no infiltrate. PI # 1 received Atrovent and Xopenex nebulizer treatments, Solumedrol and Levaquin 750 milligrams (mg.) intravenously (IV).
Physical Examination:
Vitals: Temperature 97.2, pulse 122, respirations 12, oxygen saturation 95%
and blood pressure 142/75.
General: She is an elderly appearing lady sitting in bed with shortness of breath.
Lungs: Bilateral wheezing, tachypneic, severe respiratory distress with use of accessory muscles.
Laboratory Findings: ABG (Arterial Blood Gas) at 3:00 PM: pH 7.3, PCO2 82.5, PO2 83.3, base excess 9.8, total CO2 42, Oxygen Saturation 95.9, FIO2 (Fraction of Inspired Oxygen) 60% on ten liters of oxygen.
Assessment:
1. Hypercapnia.
2. Respiratory Failure. Placed on BIPAP since PCO2 was 142.
3. Metabolic Encephalopathy secondary to Hypercapnia.
4. Active Exacerbation of COPD.
5. Sleep Apnea.
6. Chronic Lymphocytic Leukemia.
7. Diabetes Mellitus Type II.

The Physician's Order, dated January 13, 2010 at 8:00 AM, documented:
Benadryl 6.25 - 12.5 mg. every 4 hours prn (as often as necessary) IV or 25 mg. every 6 hrs po (by mouth) prn.

A review of PI # 1's MAR revealed the amount of Benadryl IV (intravenous) given to PI # 1 was not documented seven times on the following dates:
- 11/14/2010 at 9:27 PM
- 11/15/2010 at 9:30 PM
- 1/16/2010 at 2:55 PM, 9:21 PM and 3:00 AM
- 1/17/2010 at 6:20 PM and 11:09 PM.

2. Interviews:

During an interview on February 26, 2010 at 11:45 AM, the RN assigned to care for PI # 1 on January 17, 2010, reported the PI # 1 said, " I want the big dose. Don't bring me the small because it don't do nothing for me." This RN stated she gave PI # 1 Benadryl 12.5 mg (milligrams) IV, but failed to document the amount of Benadryl given on the MAR.

3. Policy:

Medication Administration Guideline, Revised 09/08:
"Purpose: To provide for safe medication management, administration and accurate documentation of the same...
J. Range Orders for Medications:
Range orders are given in dose and frequency range as outlined below:
2....The amount given will be documented along with the nurse's initials on the MAR (Medication Administration Record)."

According to Fundamentals of Nursing, A. Perry and P. Potter, copyright 2005, St. Louis, Missouri, sixth edition, pages 821 - 900, to ensure safe medication administration the nurse should be aware of the six Rights of Medication Administration that include the following:
1. The right medication.
2. The right dose.
3. The right client.
4. The right route.
5. The right time.
6. The right documentation.
"Medical errors may result from inaccurate documentation. The documentation should clearly reflect the client's name, the name of the ordered medication, the time the medication was administered, and the medication's dosage, route and frequency...After the nurse administers the medication, the medication administration record (MAR) is completed to record the medication, dose time and route...to verify the medication was given as ordered. Accurate documentation serves as a way for health care providers to communicate with each other."