HospitalInspections.org

Based on document review and interview, the Director of Nursing Services failed to ensure appropriate nursing education and competency was completed on use of new intravenous pump and tubing which led to a chemotherapy overdose on 1 of 10 (Pt1) medical records reviewed .

1. Review of policy titled: Administration and Management of Cytotoxic/Hazardous Medications, 600-017 last approved 02/09/16, indicated need for 2 certified oncology nurses for verification of all components of the order; using 2 identifiers for the patient, correct dose, route, rate and time, relevant lab studies/results and appropriate IV access with blood return. The policy was followed as the information on the pump label was correct and the nurses were certified in oncology.

2. Unable to verify a policy regarding acceptance of intravenous (IV) product from a 3rd party, what to check for and how to verify accuracy of product/supplies received.

3. A contract exists between facility 1 and facility 2 whereby facility 2 is responsible for compounding the product and attaching the tubing that is sent to facility 1 to be attached to the patient.

4. Patient 1's medical record indicated that Flourouracil (5FU) was attached to patient to run at 5.1 milliliters for 46 hours. Due to the wrong tubing being placed (infused at 175 milliliters an hour), the patient received the chemotherapy in 3 hours causing an overdose.

5. Interview with P51 Risk Manager on 02/25/19 at 1:35 pm confirmed that facility 2 had changed pumps "a couple" of weeks prior to this incident. When nursing called facility 2, they were told there was no need for an inservice as the pumps are "essentially the same".