HospitalInspections.org

Based on interviews and review of the clinical record and facility investigation the
Governing body failed to be responsible for all services in the hospital, specifically physicians and pharmacists who may and have over ridden a medication alert for patient #1.

Findings were
Interview with Staff #4, on 7-5-11 at 2:05 pm revealed that when entering the order, Staff #8, a physician, did not select " standard dosing " decision support functionality for the Computerized Physician Order entry system (CPOE) to adjust the dosage according to age, height, weight or other standards already entered into the CPOE, but Staff #8 entered each aspect of the order manually, increasing the risk for error. The order Staff #8 entered did not include the proper solution, just the vial, so the Staff #6 canceled the order and re-entered the order exactly as Staff #8 entered the order, amending only the proper solution to be an IV administration. Staff #4 stated that the CPOE would provide an alert related to inappropriate dosing based on above noted parameters. There was an alert when this order was entered that Staff #8 saw and bypassed. The alert stated that the dose was incorrect, but Staff #8 selected the reason, " Patient ' s condition warrants dose. " The pharmacist also received an alert that the dose was inappropriate,but the pharmacist also overrode the alert and sent a 100 cc mini-bag of normal saline and a 500 mg vial of Vancomycin. Two people, the physician and the pharmacist bypassed an automatic alert regarding the incorrect dose of the medication.
This was confirmed in interview with the Pharmacy director and Risk manager on 7/5/11 in the medical records meeting room.

Based on review of the clinical record, the facility report and interview with staff, patient #1 received a dose of Vancomycin (an antibiotic) 10 times the recommended amount for his weight and therefore failed to receive safe care at the hospital.

Findings were:

On 5/22/11 patient #1 presented to the emergency department with a complaint of "fever, crying since last night, nasal congestion, decreased appetite and fussiness". On 5/22/11 at 1731 a dose of 500 mg of Vancomycin was administered to patient #1, however the pediatric dosage for weight was 50 mg. The patient developed a red rash over his body. After this occurrence the patient required admission to the floor for rehydration and to be observed for symptoms from the overdose. Both a physician and a pharmacist over rode alerts in the medication ordering system that could have prevented the medication from reaching the patient. There were no policies in the Emergency department for the double verification of a pediatric dose of any medication. The parents of patient #1 requested a transfer to another acute care hospital as they did not feel safe at this hospital.
The above was confirmed in interview with the risk manager and emergency department director on 7/5/11.

Based on review of the medical record for Patient #1, Staff #7, a nurse, administered a medication for Patient #1 that was an incorrect dosage for the patient ' s age, height, and weight without clarifying the order with the ordering physician, and the nurse administered the medication at an incorrect rate of infusion.

Findings were:

Review of the medical record for Patient #1 revealed he was a 7 week old male and that measurements entered at 2:36 pm on 5-22-11 were: height per tape measure was 54 centimeters, weight on baby scale of 5.25 kilograms. Staff #8, a physician, ordered Vancomycin 100 mg/kg IV, 100 mL/hour, which was ten times the appropriate dose for an infant. Staff #7, a registered nurse reviewed and accepted the order. Staff # 6, a pharmacist, dispensed the medication. Administration of the medication by Staff #7 began at 5:31 pm and was discontinued at 6:24 pm, for a total administration time of 53 minutes, which was a more rapid administration for a small infant and not the administration time of one hour as ordered.

Interview with Staff #3, Emergency Department Director revealed that Staff #7 thought the wrong dose had been ordered, but Staff #7 did not question it or review it with another nurse. When the mixed dose arrived on the unit, Staff #7 assumed it was okay because the pharmacy sent the medication. Staff #3 stated that there was no policy in place for nurses to double check pediatric doses prior to administration in the ED, and that there is no policy for double checking pediatric doses or orders.

Staff #3 confirmed the entry in the medical record showing that the Vancomycin, ordered to be administered over one hour, was administered between 5:31 pm and 6:24 pm, a total of 53 minutes. Staff #3 did not know if the entire medication was infused over one hour and the documentation was incorrect, or if the medication infusion was stopped early and not completed. Staff #3 stated the infusion was ended for billing purposes, and the documentation related to the time of the Vancomycin was to allow the ED to bill for the infusion. Staff #3 stated that the infusion had to be completed in the ED, as this procedure would not be paid for once the patient was transferred to the floor and the ED nurses had to document that the saline lock was placed before the patient transfer to the floor for billing purposes. Staff #3 confirmed that 100 ml/hr in an infant this size is a large dose and that Staff #7 should have questioned the order, especially since the administration should have been via syringe pump as piggybacks are hardly ever done on babies.

Based on review of the clinical record for patient #1 and interview with staff #3, veracity of documentation of the time of completion of the intravenous line and placement time of the saline lock was not assured. In addition the hospital failed to follow Policy #PCADM 136, Safety Standards: Sentinel Event Policy-Disclosure.

Findings were:

-On 5/22/11 patient #1, a six week old male was ordered an intravenous antibiotic solution to run for one hour. Documentation revealed that the solution began to infuse at 1731 and ended at 1824, which would indicate the antibiotic solution ran for 53 minutes. Interview with staff #3 revealed that the documentation of the infusion was for the Emergency room billing; the infusion has to be documented as ending in the ER as an infusion won ' t be paid for on the floor and staff had to document the saline lock was placed before transfer to the floor.

-Hospital Policy #PCADM 136, Safety Standards: Sentinel Event Policy-Disclosure required action step #5 states that facts will be reviewed and shared with the patient, guardian, or representative without unnecessary delay. Required action step #7 requires the individual who has the discussion with the patient or patient ' s representative to document the discussion with the patient, guardian, and/or representative in the patient ' s medical record. Documentation to include: 1. date, time, and place of the discussion, 2. names and relationship to the patient of those present, 3. the unanticipated outcome discussed and a concise summary of the discussion, 4. steps taken to ameliorate the clinical consequences, 5. any offer of assistance or referrals (including persons or agencies) and the patient, family members or legal guardian ' s response, 6. questions posed by the patient, family members or legal guardian and the answers provided, and 7. any follow-up phone calls or conversations with patient/family. Documentation of this notification was not included within the medical record of patient #1.
The above was confirmed in interview with the risk manager and emergency department director on 7/5/11.