HospitalInspections.org

Based on document review, policy review, record review and interview, the hospital failed to ensure patients received their prescribed medications for (6) of (6) (Patient #1, #2, #3, #4, #5, and #6) patients that were reviewed for medication errors.


The findings Include:


Review of the facility's "Medication Errors and Reporting," policy approved on 8/24/2016 revealed "...Types of medication errors may include the following...Administration of wrong dose or wrong IV rate...Prescribing errors reaching the patient such as incorrect drug selection based on indications, contraindications, known allergies or existing drug therapy...Medication errors resulting in administration or omission of a medication must be documented in the patient's medical record...The person discovering the medication error is responsible for submitting a computerized incident report in Risk Plus...After an incident report is completed and submitted in Risk Plus, an email notification is sent to the Director of Quality Improvement, the Director of Human Resources, the Director of Pharmacy, and other appropriate personnel...The appropriate unit/department manager will be prompted to complete the Risk Plus entry which may require...Interviewing those involved to clarify events and determine possible causes...Counsel, education, or other forms of communication to prevent recurrence...The Risk Manager and QI Director will screen all incident reports to identify those events, including medication errors, meeting the criteria for mandatory reporting to the State..."


Review of the facility's "Incident Reports; Patient or Visitor," policy approved on 2/10/2018, revealed "...The Incident Report is used as part of the facilities integrated risk management and quality improvement program. The form must be completed for ALL unusual occurrences involving patients or visitors in the facility area or department. An unusual occurrence is defined as any occurrence involving a patient employee or visitor which is not consistent with the regular facility routine. REGARDLESS, of whether there was an apparent injury or other damage."


"...All employees of the facility are eligible, and in fact responsible, for submitting Incident Reports, as appropriate. Appropriate follow up will be initiated by the Risk Manager, Chief of Human Resources Officer, Chief Nursing Officer, or Director of Quality Improvement..."


"...When an even occurs, a facility Incident Report is completed by personnel aware of the occurrence ...If the occurrence involves a patient, chart precisely the necessary information on the patient's electronic medical record..."


Review of the medical record revealed Patient #1 entered the Emergency Room with severe chest pains on 4/24/2022 with allergies to Hydrocodone, Levofloxacin, and Losartan noted in his medical file.


Review of the History and Physical Note written by Physician #3 dated 4/24/2022, revealed, "...Acute right sided chest pain, rule out acute coronary syndrome-likely musculoskeletal however..."


Review of the Physician's Order dated 4/24/2022, revealed "...Morphine [Narcotic]...2 mg [milligram]/1 ml [milliliter]...IVP [Intravenously piggy backed]...Last Given...4/24/2022...at 18:57 [6:57 PM]..."


Review of the ED [Emergency Department] Course note written by Physician #1 dated 4/24/2022, revealed "...Patient was handed off to me by [Named Physician #2 ] all labs were returned prior to departure of the previous physician as well as the chest x-ray. I still took over to manage the case I went into the room discussed with the patient he did not have reproducible palpatory tenderness to the right medial chest wall that was consistent with his complaint...He did get improvement with nitro [Vasodilator]...After sublingual nitro paste applied. Aspirin [Blood Thinner] given..."


Review of the Physician's Order dated 4/24/2022, revealed "...Nitroglycerin...0.4...SL [sublingual]...every 5 min [minutes] x 3 as needed for chest pain...Last Given...4/24/2022...19:27 [7:27 PM]..."


Review of the Physician's Order dated 4/24/2022, revealed "...Baby Aspirin...324 mg...po [by mouth]...once...Last Given...4/24/2022...at 19:47 [7:47 PM]..."


Review of the Physician's Order dated 4/24/2022, revealed "...Nitro-Bid...0.5 inch...TD [topical]...Last Given 4/24/2022...20:40 [8:40 PM]..."


Review of the Physician's Order dated 4/24/2022, revealed "...Zosyn [Antibiotic] 4.5 mg/ns [normal saline]100 ml...IVPB...Last Given...4/24/2022...20:40 [8:40 PM]..."


Review of the Patient Medication Profile revealed "...Zosyn 4.5 gm [gram]/NS [Normal Saline] 100 ml...to be given in the emergency room...Start ...04/24 [2022] 20:26 [8:26 PM]...Stop...04/24 [2022] 20:38 [8:38 PM]..." The Antibiotic ran for 12 minutes before it was discontinued.


Review of an email from [Named Customer Service Vendor] revealed "...Received date...4/29/2022...2. Your trust in the skill of the staff who provided your test or treatment...POOR...Response to concerns/complaints made during your visit...FAIR...Your Care Comments Section...I was given the wrong medication and was told it was ordered for the patient next to me but got sent on my chart. What if this had been something that could have killed me luckily my wife is a nurse questioned the medication and asked to speak to the dr after the nurse has already administered the drug Zosyn. They came back in and stopped it an apologized. This could have turned out bad..."


During a telephone interview with the complainant on 6/15/2022 at 9:33 AM, the complainant stated "...I didn't call your [surveyor] office...I filled out a survey from the hospital...I was concerned that my husband received a medication he could have had a reaction from and the physician just laughed it off saying 'everyone makes mistakes'...we had to wait in the waiting room for 15 minutes and anyone with chest pain should take precedence...the triage nurse did all the testing...he finally received an aspirin and nitroglycerine patch...my husband was admitted overnight for observation...The care on the floor after he was admitted was excellent but the care in the emergency room was awful...I'm a nurse at [Jackson Madison County General Hospital] and know what should have taken place..."


During a telephone interview with Physician #1 on 6/16/2022 at 1:31 PM, the physician was asked if he recalled [Patient #1]. The physician stated, "...I thought they were pleased with the care I gave them...they were very complementary..." The physician was asked why Patient #1 was prescribed Zosyn. The physician stated, "...It was a mistake...I had the patient pulled up [on the computer] and it was prescribed for a lady [patient] in another room with severe pneumonia..." As soon as I realized the error, I rushed into [Patient #1]'s room and removed the antibiotic. They seemed to understand it was just human error..." The physician was asked if he was familiar with the hospital ' s policy regarding charting the medical error. The physician stated, "...no I am not aware of the policy, but I normally would document that anyway in the medical record...I will definitely look into that and write an addendum if I need to..."


The Director of ED [Emergency Department] confirmed there was no documentation in Patient #1's medical record of the medication error by the nurse or physician.


The Director of ED confirmed she was not aware of antibiotic administered in error to Patient #1.


During an interview with the Director of the Emergency Department and the Quality Director and Risk Manager confirmed both the nurse and physician should have noted the medication error in their progress notes.


Review of the medical record revealed Patient #2 was admitted to the facility on 2/4/2022 with complaints of weakness and left lower leg pain for 2 weeks.


Review of the Patient Information Form dated 2/4/2022, revealed "...Discoloration of bilateral lower extremities noted with cyanosis noted to left toes. Less than 2-second cap [capillary] refill left foot and 2+ pedal pulses in left foot..."


Review of the History and Physical dated 2/4/2022, revealed "...Doppler of lower extremity found occlusion from the superficial femoral artery to the posterior tibial and peroneal arteries. The dorsalis pedis artery is also occluded. There is deep vein thrombosis in the superficial femoral vein and popliteal vein...Heparin protocol initiated in ER..."


Review of the Incident Report dated 2/4/2022, revealed "...Heparin protocol ordered and initiated in the ED...with weight of 117 kg [kilograms] [254.941 pounds]...Heparin policy was not found on the chart...Protocol was brought up later by house supervisor...Education for staff provided on Heparin protocol ..."


Review of the undated facility's ACS [Acute Coronary Syndrome] Cardiology Heparin Infusion Protocol revealed, "...Administer initial weight-based heparin bolus using the chart below. Obtain heparin 5,000 units/1 ml [milliter] vial from automated dispensing machine...66 [kg] and above...4,000 units=0.8 ml [Initial Bolus]...1,980 units=0.4 ml [Rebolus]..."


During an interview with the Emergency Room Director on 6/15/2022 at 11:25 AM, stated "...we have weight stretchers and he [Patient #2] might not have realized he was being weighed ...he may also have stated his weight in the ER...The heparin dosage was the same for both weights...Education is usually verbal. If it was a patient harm event, it would be written...the patient suffered no injury."


Review of the medical record revealed Patient #3 was admitted to the facility on 1/26/2022 with diagnoses of Abdominal Aortic Aneurysm, with Active Leak and Hypertensive Urgency.


Review of the Physician Order dated 1/30/2022, revealed "...Fluticasone-Furoate-Vilanterol 200-25 mg/dose...1 inhalation...once a day..."


Review of the Medication Administration Record (MAR) dated 1/30/2022, 1/31/2022, 2/1/2022, and 2/2/2022, revealed the medication Breoellipta had been documented as given. Patient #3 had been transferred from the Critical Care Unit to 3rd Tower on 1/31/2022 and medication had been left in Critical Care and was still sealed and all the doses were present.


Review of the Incident Note dated 2/2/2022, revealed "...Patient was ordered Breoellipta on 1/30/2022. Medication is charted as given on each shift per MAR. Medication was not in patient's bin on 3 T [tower]. I located the medication in CCU [Critical Care Unit] Pyxis [automatic medication dispenser]. Inhaler was sealed and all doses present ...Action Taken: None..."


During an interview with the Critical Care Nurse Director on 7/5/2022 beginning at 12:58 PM, she was asked how many doses were missed and what was done to correct the issue. She stated, "...It appears that 72 hours' worth...There was no follow up...I verbally counseled the nurses..." She was asked if there was any documentation the physician was notified of the missed medication. She stated, "...We don't see anything in the medical record..."


Review of the medical record revealed Patient #4 was admitted to the hospital on 1/27/2022 with diagnoses of Community Acquired Bilateral Pneumonia, related to SARSCoV2 (COVID19) Infection, Acute Hypoxic Respiratory Failure, Coronary Artery Disease, Diabetes Mellitus, and Hypertension.


Review of the Incident Report dated 1/29/2022, revealed "...Found a cup with packaged medications at bedside. Medications were documented as given at 0529 [5:29 AM] but clearly were not. Notified [Michelle], Director ...Nature of Injury: Can't determine...Action Taken: None..."


During an interview with the Director of Med Surg [Medical Surgery] on 7/5/2022 beginning at 12:58 PM, she was asked to describe the medication error. She stated, "...This incident was brought to me as well as the medication cup with the medications in it when I got to work. I called the nurse into my office to counsel her and explain that she had fraudulently documented medications were given. After that meeting, she resigned..." She was asked if there was documentation in the patient's medical record of the medication error. She stated, "...Not that I am aware of..." She was asked if the physician was notified of the medication error. She stated, "...we don't see where they [staff] notified the physician..."


Review of the medical record revealed Patient #5 was admitted to the facility on 3/24/2022 with diagnoses of Dorsalgia, Pneumonia, Congestive Heart Failure, and Urinary Tract Infection.


Review of the Incident Report dated 3/25/2022, revealed "...An orientee nurse...gave a whole tablet of Tramadol 50 mg instead of ½ tablet or 25 mg. No adverse reaction noted...PA notified and no orders made...Education was given to the new nurse regarding not opening medication until you are inside the patients room No harm to the patient..."


During an interview with Director of Med Surg on 7/5/2022 beginning at 12:58 PM, she was asked what was done to prevent the incident from happening again. She stated, "...I spoke with the nurse..."


Review of the medical record revealed Patient #6 was admitted to the hospital on 6/5/2022 with diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease Dependent on Oxygen, Right Lower Lobe Abnormality on Chest X-ray Questionable Pneumonia Versus Radiation Scarring, and Hypertension.


Review of the Incident Report dated 6/6/2022, revealed "...Pt [Patient] HR [heart rate] elevated. Notified...NP [Nurse Practitioner] and was told to give schedules 120 mg Diltiazem po for 1800 early...RN gave early dose and charted accordingly. STAT [rush] order for same drug showed up on the MAR and was administered...Nature of Injury: Can't determine...Comments: After researching it looks like 2 doses were put in. One at 12:46 and one at 15:15 [3:15 PM] these were given. Patient was monitored and no harm. Pharmacy pushed both orders through. They were verbal orders and put in by the nurses...Action Taken: Case Closed..."


During an interview with the Director of Med Surg on 7/5/2022 beginning at 12:58 PM, she was asked if the medication error was documented in the patient's medical record. She stated, "...I don't see anything documented..." She was asked what was done to prevent the medication error in the future. She stated, " ...pharmacy did not catch the error and pushed both of the orders through ...there is a new process in place for order entry ..."


She was asked if medication errors should be documented in the patient's record. She stated, "Yes. When there is a medication error, there should be [documentation]..." She was asked if there should be documentation when there is a medication error, and the physician is notified. She stated, "...There should have been..."


During an interview on 6/15/2022 at 3:00 PM, with the Quality Director and Risk Manager, she confirmed she had no idea of the medication error during Patient #1's hospital stay and was getting with the customer service vendor on how she will be able to view the survey's promptly, and she was asked what was put in place to prevent these incidences from happening again. She confirmed that she looks at the incidences and they are taken to the hospitals Quality Assurance meeting. Depending on the type of incident, it was 'kicked' to the appropriate department head. She was asked again, as Risk Manager, how did she ensure these incidences didn't happen again. She confirmed the incident investigation needed to be more thorough and if education was given, it needed to be documented. She also confirmed "No Action Taken" was not a suitable answer.


During an interview with the Quality Director and Risk Manager on 7/5/2022 beginning at 12:58 PM, she was asked if she had access to the incident investigations and evaluate the thoroughness of the investigation. She stated, "...I can go in and look at all of the incident reports and follow up with that Director. From now on, Directors will have to document some action taken and document what was done as far as education ..." She was asked if the investigations at this point were thorough as they needed to be. She stated, "...thorough as they need to be? Uh, some are, and some are lacking for example notifying the physician...we have several opportunities since 4 of 6 medical records did not have documentation of the medication error..." She was asked if she had reviewed the hospital policies regarding medication errors and incident reporting. She stated, "...I'm sure I did at that time...we can look at them again..."