HospitalInspections.org

Based on the review of medical records, it was determined that in six of ten medical records of individuals who received anesthesia services, medical records # 2, 3, 4, 7, 9, and 10, the hospital failed to ensure the administration of medications according to accepted standards of practice. Findings:

Medical records # 2, 3, 4, 7, 9, and 10 contained a form entitled Anesthesia PACU Orders signed by the Certified Registered Nurse Anesthetist (CRNA). The form listed the following medications under the section entitled Medications For Pain: Fentanyl; Demerol for pain/shivering; Demerol for pain; two entries for Morphine; Dilaudid; and Toradol. Each medication name was followed by a dose, route of administration, frequency, and maximum dose. Each medication name was preceded by a blank line. The Anesthesia PACU Orders form in each of the medical records listed above reflected documentation by the CRNA of a check mark in front of at least two of the medications in the list. Each form lacked identification of the order in which medications were to be administered, first and second. This failed to ensure that all drugs were administered in accordance with State laws and failed to ensure that orders for medications were written with clear direction for the administration of the medication according to accepted standards of practice.

An interview of a representative of the Oregon State Board of Nursing determined that physician/practitioner order forms should be designed and implemented to avoid requiring a nurse to make a judgement as to which medication (or medications) to administer from a menu of medications. The orders should rank the medications as to which medication should be given first, second, etc. and the orders should specify a maximum dose for each medication before administering another medication. The decision to select a drug from a list or menu of drugs is beyond the scope of practice of the Registered Nurse, not in keeping with "prudent, safe, nursing practice standards," and borders on prescriptive responsibilities.

Findings include the following examples:
The Anesthesia PACU Orders in medical records # 2, 3, 4, and 7 each contained checkmarks in front of the following medications:
Fentanyl 25-50 mcg IV q 10-15 min PRN for pain; the maximum dose was individualized for the patient; and
Dilaudid 0.5-2 mg IV q 10 (sic) PRN for pain (2 mg total dose).

The Anesthesia PACU Orders in medical record # 10 contained a checkmark in front of the following medications:
Fentanyl 25-50 mcg IV q 10-15 min PRN for pain (150 mcg maximum); and
Demerol 5-12.5 mg IV q 10-15 min PRN for pain/shivering (25 mg maximum).

The orders were not ranked as to which medication should be given first, second.