HospitalInspections.org

Based on interview and record review the facility failed to ensure medications were safely administered in 1 of 18 patients (Patient #4).


This deficient practice had the likelihood to cause harm to all patients on the intravenous antibiotic Vancomycin.

Findings include:




Review of clinical record of Patient #4 revealed she was a 55 year old female who was admitted on 08/22/2017. Patient #4 had diagnoses which included polycystic kidney disease, liver disease, hypertension and intraabdominal infection.


Review of physician orders revealed Patient #4 was started on the antibiotic Vancomycin I Gram intravenously every 12 hours on 09/02/2017. The following instructions were written on the orders:

"Pharmacy will follow Vancomycin and make necessary dosage adjustments. Please note Vancomycin trough ordered at 1930 on 09/08/2017, 30 minutes prior to the scheduled dose. Hold Vancomycin for trough >20mcg/mL."


Review of laboratory results revealed a Vancomycin Trough was at a level of 18.3 on 09/04/2017 (08:00).


Review of the medication administration record revealed Vancomycin doses were scheduled to be administered at 8:00 a.m. and 8:00 p.m. everyday.


Review of laboratory results revealed there was no trough lab report for 09/08/2017 for 7:30 p.m.

Review of the medication administration record revealed on 09/08/2017 at 8:53 p.m., the dose of Vancomycin was documented as being given.

Nursing administered the medication without knowing the trough level.


Review of the laboratory results revealed the next documented Vancomycin Trough was high at a level of 27.5 on 09/09/2017(00:21). Which was 3 hours after the 8:00 p.m. dose of Vancomycin was administered on 09/8/2017.


Staff #3 confirmed the missing lab results and the time the medication was administered. Staff #3 reported that lab was drawn before the 8:00 p.m. dose of medication,but was not resulted out until 0021 for some unknown reason.


Review of a facility policy's named "Vancomycin Monitoring Protocol" dated 09/2017 revealed the following:

"Vancomycin is a narrow-spectrum glycopeptide antibiotic with potent antistaphylococcal activities..A number of studies conducted within the last decade have given new insight into the potential for both ototoxicity and nephrotoxicity associated with vancomycin use ....Therefore, appropriate use of serum drug level monitoring (SDLM) is necessary particularly in patients receiving other potentially nephrotoxic or ototoxic agents."

Indication for drawing vancomycin level(s) ...
Patients receiving vancomycin therapy for greater than or equal to 5 days ...

Timing of Vancomycin Levels:
Trough levels: Will be drawn approximately 30 minutes prior to next dose."



Review of a facility's policy named "Medication, Preparation, Dispensation, And Administration" dated 11/2015 revealed the following:


" ...The licensed nurse has the responsibility to administer medications safely according to the 5 rights: patient, time,drug, dose, and route.


PROCEDURE:

Timing of Medications
Timing of medication administration is based on the nature of the medication and its clinical application, to ensure safe and timely administration ..."