HospitalInspections.org

Based on staff interview and record review, the facility failed to ensure the timely clarification for physician ordered medications for 1 of 9 patients, (Patient #1).

Findings:

Review of the medical record for Patient #1 revealed a Neurosurgeon's post op orders written on 10/24/2016 and faxed to the pharmacy on 10/24/2016 at 12:24 PM. Review of the written order revealed under Allergies: Lisinopril and Tape, under Call MD if: SBP is less that 100 OR greater that 170, and under other: Vasotec 1.25 mg IV Every 4 hours As Needed SBP>160, may repeat x1 if ineffective.

Review of the medical record for Patient #1 revealed that on 10/25/2016 at 7:37 PM the patient experienced a blood pressure of 186/91 and again at 11:10 PM a blood pressure of 171/84. The medical record revealed that the Vasotec was placed on hold by the pharmacy staff and not available to the patient until 9:15 PM on 10/25/2016.

Interview with the Director of Pharmacy on 1/19/2017 at approximately 4:30 PM revealed that the original order for Patient #1 written on 10/24/2016 for Vasotec was placed on hold by a pharmacist. The reason stated by the Director of Pharmacy was that Lisinopril was listed as a drug allergy and Vasotec is in the same drug family as Lisinopril. The Director of Pharmacy stated that routine medication orders are reviewed by offsite pharmacists and if a concern is found the order is placed on hold for the in-house pharmacist to review and get clarification. He stated that the review did not occur and was not discovered until the nurse called the pharmacy on 10/25/2016.

Review of the medical record did reveal that the nursing staff had discovered that the original order was not transferred to the Medication Administration Record (MAR) until the nurse assigned to the patient on 10/25/2016 reviewed the medical record to determine if a PRN antihypertensive was ordered.

Based on staff interview and record review, the facility failed to ensure the timely clarification for physician ordered medications for 1 of 9 patients, (Patient #1).

Findings:

Review of the medical record for Patient #1 revealed a Neurosurgeon's post op orders written on 10/24/2016 and faxed to the pharmacy on 10/24/2016 at 12:24 PM. Review of the written order revealed under Allergies: Lisinopril and Tape, under Call MD if: SBP is less that 100 OR greater that 170, and under other: Vasotec 1.25 mg IV Every 4 hours As Needed SBP>160, may repeat x1 if ineffective.

Review of the medical record for Patient #1 revealed that on 10/25/2016 at 7:37 PM the patient experienced a blood pressure of 186/91 and again at 11:10 PM a blood pressure of 171/84. The medical record revealed that the Vasotec was placed on hold by the pharmacy staff and not available to the patient until 9:15 PM on 10/25/2016.

Interview with the Director of Pharmacy on 1/19/2017 at approximately 4:30 PM revealed that the original order for Patient #1 written on 10/24/2016 for Vasotec was placed on hold by a pharmacist. The reason stated by the Director of Pharmacy was that Lisinopril was listed as a drug allergy and Vasotec is in the same drug family as Lisinopril. The Director of Pharmacy stated that routine medication orders are reviewed by offsite pharmacists and if a concern is found the order is placed on hold for the in-house pharmacist to review and get clarification. He stated that the review did not occur and was not discovered until the nurse called the pharmacy on 10/25/2016.

Review of the medical record did reveal that the nursing staff had discovered that the original order was not transferred to the Medication Administration Record (MAR) until the nurse assigned to the patient on 10/25/2016 reviewed the medical record to determine if a PRN antihypertensive was ordered.