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UMASS MEMORIAL MEDICAL CENTER INC 55 LAKE AVENUE NORTH WORCESTER, MA 01655 May 2, 2013
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of the Hospital's Internal Investigation (HII) involving a medication overdose/error for one patient ( Patient #1) that occurred on 2/12/13, the Hospital failed to identify that Pharmacist #1 entered the incorrect medication dose into the pharmacy computer system without a written or verbal physician order; and Physician #1 failed to write the Clonidine order according to the Hospital policy titled " Medication Ordering." Finding include:

Review of the HII did not identify that:
1.) Pharmacist #1 entered the incorrect medication dose into the pharmacy computer system without a written or verbal physician order,
2.) Physician #1 did not write the medication order according to the Hospital policy titled Medication Ordering.

The Surveyor interviewed Pharmacist #2 (conducted the HII) at 11:00 A.M. on 4/30/13 regarding the HII. Pharmacist #1 said she entered the medication, Clonidine, into the pharmacy computer system without a physician written or verbal order, in an attempt to expedite delivery of the medication, to the PICU and because she knew Patient #1's Clonidine dose from his/her previous admission.

Pharmacist #1 said she entered into the pharmacy computer system a dose that was 10 times the dose of Clonidine intended and self-reported her medication error to the Hospital. Pharmacist #1 said she typed a dose of 0.06 mg instead of the intended correct dose of 0.006 mg of Clonidine.

The Hospital policy titled Medication Ordering dated 1/25/12 indicated that oral liquid medications should be ordered by dosage (for example, mg); not volume (for example, ml).

The Admission Physician Orders dated at 1:15 P.M. on 2/11/13 indicated Patient #1's medication order for Clonidine was 0.06 milliliters (ml) [0.01 mg (milligrams)/ml] to be given by mouth and to be administered every eight hours.

The Surveyor interviewed Physician #2 at 1:45 P.M. on 4/30/13. Pediatrician #2 said that he was not sure what the Hospital Medication Ordering Policy stated. Physician #2 said that he was conducting education with residents on service about writing medication orders in milligrams, not milliliters.

The Surveyor interviewed Registered Nurse (RN) #1 at 9:45 A.M. on 5/13/13. RN #1 said that she knew that the Clonidine order should be written by the physician in milligrams and not milliliters, tried to contact the physician but did not contact the physician. RN #1 said that she did not handoff in nursing shift report that the Clonidine medication order was written incorrectly and needed to be clarified by the physician.

The Surveyor interviewed the Nurse Manager at 10:35 on 5/1/13. The Nurse Manager said that Hospital policy indicated that a medication dose was ordered in dose not volume (ml are volume) and that nursing staff should have clarified the Clonidine order with a physician. The Nurse Manager said that staff education was done informally during the nursing change of shift report and that formal education was not conducted.

Pharmacist #2 said she did not distribute the information regarding the Hospital's Medication Ordering Policy, specifically addressing the issue of not processing a medication order, written in volume, until the dose was clarified by a physician, to all pharmacists.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
Based on review of 1 (Patient #1) of 12 medical records and interviews the Hospital failed to ensure that a medication, Clonidine (used to treat narcotic withdrawal), was dispensed in accordance with professional standards of practice because Pharmacist #1 entered into the pharmacy computer system an order for Clonidine without a physician's order. Findings include:

1. The Surveyor interviewed Pharmacist #2, at 11:00 A.M., on 4/30/13 regarding a medication error for Patient #I. Pharmacist #1 said she entered the medication, Clonidine, into the pharmacy computer system without a physician written or verbal order, in an attempt to expedite delivery of the medication, to the Pediatric Intensive Care Unit (PICU) and because she knew Patient #1's Clonidine dose from his/her previous admission.

The Surveyor interviewed Pharmacist #4 at 10:40 A.M. on 5/2/13. Pharmacist #4 said neither he ( the Pharmacy Director) or Pharmacist #3 (Pharmacy Clinical Manager) were aware that Pharmacist #1 did not have a physician written or verbal medication order for Clonidine until after Pharmacist #1's interview with the Surveyor on the previous afternoon, at 2:45 P.M. on 5/1/13. Pharmacist #4 said he did not yet have a remediation or supervision plan for Pharmacist #1.