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MUNSON HEALTHCARE CADILLAC HOSPITAL 400 HOBART ST CADILLAC, MI 49601 March 1, 2013
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review, the facility failed to follow policy and procedure and safe medication administration for 1 (patient #1) of 10 patients reviewed resulting in a medication error and patient harm and the potential for patient harm for all patients treated at the facility. Findings include:

During an interview with the Chief Quality Officer (CQO) on 03/01/2013 at 9:30 AM, she confirmed that a 28 day old infant (patient #1) was admitted on [DATE] and was given an incorrect dose of Ceftriaxone that was administered per an incorrect IV route. When queried as to what had occurred she stated that "we use bar code scanning, the nurse (RN #1) scanned the medication that she had gotten out of the refrigerator and the machine alerted (beep and screen display) 'No order found' the nurse then over rode the bar code scanner and administered 1000 mg of medication instead of the ordered 125 mg". The mistake was discovered when the pharmacist brought the correct medication out for the patient and gave it to RN #1 to administer. The nurse (RN#1) asked the pharmacist "what is this, and he replied "it is the medication that you were waiting for". RN #1 replied "No, I just gave that patient their medication". "It was then revealed that the medication error had occurred". During the interview with the CQO, she also stated that "the medication was administered to the infant, IV push and that the order was for IVPB (IV piggy back)". The CQO also produced a 10 ml syringe with a different patient's name on it and stated "this is what she gave." The syringe was labeled correctly from pharmacy with the another patient's name, type of drug, dose of medication, time and route it was to be administered. When asked about double checks of medications for pediatric patients she stated "the bar code scanner is supposed to be the second check and they are not supposed to override it".

During review of the medical record for patient #1 on 03/01/2013, revealed that the patient was a "28 day old infant admitted on [DATE] for 'fever of uncertain source'". Per nursing assessment documentation on 10/23/2012 the infant's weight was "5 kg" (kilograms). On 10/24/2012 at 9: 51 AM the physician entered an electronic order for "Ceftriaxone 25 mg/kg, IVPB ( IV piggyback) every 12 hours, please give now". On 10/24/2012 at 10:46 AM, RN #1 documented administration of a "125 mg dose of Ceftriaxone" to patient #1. (The medication administration documentation revealed that at 10:46 AM, RN #1 administered Ceftriaxone (Rocephin) to patient #1). The next entry into the medical record was at 12:40 PM from the physician noting "the medication error of a 1000 mg dose of Ceftriaxone being administered to patient #1 by RN #1 at 10:46 AM, examining the infant, speaking with poison control, the pharmacy, Facility B Hospital's Pediatric Pharmacist, the infant's parents and initiating a transfer to Facility B Hospital after speaking with the accepting physician (Staff M)".

During an interview with RN #1 on 03/01/2013 at 4:30 PM, she confirmed that she did administer the medication to the wrong patient, she stated that she "calculated the dose in her head and thought that it was right" and gave it to patient #1. When asked to explain what happened she stated "I checked the refrigerator for the medication and thought that the medication that I got was for the patient, I scanned it with the bar code scanner and it read {No order found} and I over-rode the scanner and gave the medication". When asked about giving the medication IV push instead of IVPB, as it was ordered she stated "I thought the cool medication would feel good going in since she was running a temp". She went on to say that she "realized my mistake when the pharmacist brought out the medication for the patient and gave it to me". When asked about following the "five rights" when administering medications she stated that she "was just trying to get the medication administered to help the patient".

A review of Facility A's policy number SMOP 41 approved 02/23/2012 titled "Bar Coding Medication Administration (BCMA)" V3 reads on page 1 under Policy Statement: "Positive patient and medication identification, using bar coding technology, has been proven to reduce medication errors. The purpose of this policy is to provide procedures for processing medication and IV solution orders and the maintenance of an electronic medication administration record including barcode medication administration via Care Mobile". Page 2 of the document reads "E. Medication Administration Procedure/Documentation Using the PDA Tool:
1. The nurse reviews the MAR summary in Powerchart at the beginning of each shift, before and after documenting medication administration, and at shift change.
2. Prior to administering medications, the nurse signs the PDA, and selects the correct patient name. The PDA opens to the 'Due Tasks' folder.
3. The nurse selects the correct folder (Due Tasks, Overdue Tasks, PRN,etc..) in which the medication to be administered is located.
4. The entire medication order is read prior to administering the medication, including all instructions and warnings.
5. The medication is obtained and scanned using the PDA. The PDA and the medication are brought to the patient for verification against the patient's wristband.
A. All medications remain in their packaging until immediate administration to the patient.
B. The patient is identified using the two identifiers: patient's full name and date of birth. If the patient is non-verbal, the information printed on the wristband is compared against what is displayed on the PDA.
6. The nurse scans the patient's wristband to re-identify the patient to the PDA and then administers the medication.
7. The nurse signs that the medication has been given in the PDA".

Further review of the Facility A's policy number SMOP 20 approved 01/07/2013 titled "Medication Administration Standards" V13 reads on page 2:
6) "All staff administering medications on any in-patient nursing unit are to be trained in and shall strictly use Bar Code Medication Administration (BCMA) techniques prior to giving medications (refer to policy SMOP #41)."
8) "Other scheduled medications are to be administered within 60 minutes of their scheduled times. 'Stat' medications are to be administered immediately or as soon as available. 'Now' medications are to be administered within 30 minutes of being prescribed. 'PRN' or 'as needed' medications are to be administered when the patient meets the criteria as defined by the provider or protocol for therapy."
9) "The 'Five Rights' are verified prior to administering medications: Right medication, Right dose, right route, right person, right time."
11) "The medication packaging is visually checked (all patient care areas) and scanned (in-patient nursing areas only) against the order before administration: Check before removing from the package, check after removing from the package."
15) "Prior to administering medications to a patient, the patient's identification is verified by two identifiers-the patient's name and date of birth, The patient is asked to state their name and date of birth, which is verified against the patient's identification band and the MAR (Medication Administration Record). If the patient is unresponsive, the patient's name and date of birth on the identification bracelet are verified against the documentation to be used for medication administration. The PDA with the patient's medication task displayed is taken to the patient's bedside (in-patients). The patient's wristband is scanned prior to administering the medication to verify the patient's specific medication profile is being used. "

Conclusion: The facility was noncompliant with policies for:
1. positive patient and medication identification prior to administration using the bar code technology
2. reading the entire medication order prior to administration, including all instructions
3. medications are brought to the patient for verification against the patient's wristband
4. scanning the patient's wristband to re-identify the patient to the PDA and then administering the medication
5. verifying the "five rights" prior to administration of a medication.