HospitalInspections.org

Based on document review and interview, it was determined for 1 of 10 (Pt #1) Emergency Department patient, medication was removed from an automated dispensing machine with an override function by a nurse prior to reviewing the patient profile for drug allergies. This has the potential to affect all patients serviced by the Emergency Department.
Findings include:

1. The policy titled "Automated Dispensing Machine Override" (revised 7/1/13) was reviewed on 7/8/15 at 11:00 AM. The policy stated "C. ...the nurse will be able to obtain the medication from the Automated Dispensing Machine by using the override function without the order first being reviewed by a pharmacist as long as the following process is completed. 1. The nurse must first check the patients profile with regard to medication allergies, appropriateness of dose, and adverse drug reactions prior to giving the medication."

2. Pt #1 presented to the ED (Emergency Department) on 3/10/15 at 9:44 PM with complaint of chest pain. Pt#1's triage assessment was completed and computer profile listed Morphine Sulfate as a medication allergy. MD #2 (ER physician) ordered Morphine Sulfate 5 mg IV at 10:35 PM but deleted the order at 10:36 PM and then ordered Fentanyl 100 mcg IV at 10:38PM. E#4 (ER nurse) removed Morphine 10mg injection from the Pyxis (Automatic Medication Dispensing System) on 3/10/2015 at 10:38 PM using the automatic overide function without noting Pt#1's listed Morphine Sulfate allergy. Pt #1 received Fentanyl at 10:43 PM by E#4. The narcotic waste log dated 3/11/2015 indicated at 5:52 AM Morphine 10mg IV was wasted.

3. An interview with E #8 (Emergency Department Manager) was completed on 7/7/15 at 1:30 PM. E #8 stated the expectation of nursing staff in ED accessing the Automatic Dispensing Machine with an override is to first check the patient profile with regard to medication allergies, appropriateness of dose, and adverse drug reaction prior to giving the medication.