The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ALOMERE HEALTH 111 17TH AVENUE EAST ALEXANDRIA, MN 56308 July 23, 2014
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and document review the hospital failed to have an effective Governing Body to provide oversight to a contracted service for the safe delivery of anesthesia services. The contracted services (including the anesthesia services contract) had not been reviewed by the Governing Body in 16 months. The hospital did not have anesthesia medications available for 1 of 11 patients reviewed and no backup plan for the availability of medications. Therefore, the hospital was unable to meet the Condition of Participation of Governing Body at CFR 482.12. This deficient practice had the potential to impact all patients receiving anesthesia services from the hospital.

See A-0084- Based on interview and document review the hospital Governing Body failed to ensure that services performed under a contract were provided in a safe and effective manner for 1 of 11 patients (P1) when the hospital failed to make anesthesia medications available at the time of surgery. Findings include:
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on interview and document review the hospital Governing Body failed to ensure that services performed under a contract were provided in a safe and effective manner for 1 of 11 patients (P1) when the hospital failed to make anesthesia medications available at the time of surgery. Findings include:

The Anesthesia services agreement with the hospital and an external anesthesia company dated 11/23/2009 and updated 4/14/2014 established that the employees of the anesthesia company including: Anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) are independent contractors working with respect to hospital employees to provide services pursuant to the agreement. In addition, the agreement stated it is understood and agreed that the sole interest of the hospital is to assure that the work and services covered under the agreement are performed in a competent, efficient and satisfactory manner and in accordance with hospital and medical staff rules and regulations as well all applicable law. The agreement defined that all equipment deemed by the parties to be necessary for the efficient and safe conduct of anesthesia procedures shall be provided and furnished by the hospital at the sole expense of the hospital. In addition, the hospital would be responsible to purchase all necessary supplies and equipment for the anesthesia department including, but not limited to: non-medical items needed in the administration of anesthesiology.

During an interview on 7/16/2014 at 11:35 a.m., CRNA-F stated at the beginning of P1's surgery; the lock mechanism on his anesthesia medication box failed and he was unable to obtain the narcotic medication needed for P1's surgery. CRNA-F stated he took the box to the pharmacy for assistance however, the box would not open and pharmacy did not provide a second box of medications. CRNA-F decided to use medications from the Medical Doctor of Anesthesiology (MDA)'s box. CRNA-F was not familiar with the set up of the medications in the box. As a result, CRNA-F administered the wrong medication to P1.
The hospital pharmacy policy dated 9/12 and titled Controlled Substances: Anesthesia Boxes established that each contracted Certified Registered Nurse Anesthetist (CRNA) and Medical Doctor of Anesthesiology (MDA) is supplied with two narcotic medication boxes.

Pharmacy Director (PH-E) was interviewed on 7/16/2014 at 3:10 p.m. and stated the contents of these boxes is approved by the medical staff Performance Improvement Committee.

The hospital CEO was interviewed on 7/23/2014 at 12:00 p.m. and stated the list of contracted services is reviewed by the Governing Body annually. He stated the Medical Staff Process Improvement (PI) committee collects and reviews the data for performance improvement for each of the contracted services. The data is then approved by the Medical Executive Committee (MEC) and then forwarded to the Governing Board for approval. However, the most recent list of contracted services was reviewed and signed by the governing body 3/15/2013. The CEO verified the current list of contracted services (including the contract with an outside anesthesia company) had not been reviewed by the Governing Body in 16 months and is scheduled to be reviewed by the end of the week. In addition, the list will have bypassed the MEC review process in an effort to have it approved by the Governing Board timelier and will then go back to the MEC for review and approval.

The CEO acknowledged he was unsure why CRNA-F was only using one anesthesia narcotic box and that no one would have had the authority to make that decision. He stated that policy should have been followed and CRNA-F should have been provided with two locked anesthesia narcotic boxes.
VIOLATION: QAPI Tag No: A0263
Based on interview and document review the hospital failed to implement and maintain an effective, ongoing, hospital wide, data driven quality assessment and improvement program that focuses on the prevention and reduction of medical errors. The cumulative effect of these systems problems resulted in the hospital's inability to maintain effective quality assurance performance improvement processes in order to ensure the provision of quality health care. Therefore the hospital was unable to meet the Condition of Participation of Quality Assessment and Performance Improvement Program CFR 482.21. These deficient practices had the potential to impact all patients receiving services from the hospital. Findings include:
See A-0283 - Based on interview and document review the hospital failed to use the Quality Data, including medication error data, to identify opportunities for improvements in pharmacy services for 6 of 11 patients, Patient (P)-12, P-13, P-15, P-24, P-16, and P-18, who required pharmacy services during the pharmacy's non-pharmacist hours and those services were not delivered timely and/or accurately..
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review the hospital failed to use the Quality Data, including medication error data, to identify opportunities for improvements in pharmacy services for 6 of 11 patients, Patient (P)-12, P-13, P-15, P-24, P-16, and P-18, who required pharmacy services during the pharmacy's non-pharmacist hours and those services were not delivered timely and/or accurately.Findings include:

Medical record review revealed P-12 was admitted on [DATE] with diagnoses that included sepsis. A review of the hospital medication error report dated 4/26/2014 revealed P-12's physician ordered a pharmacy consult for pharmacy to dose Vancomycin on 4/26/2014 at 6:30 p.m. The medication was not administered as ordered. The medication was not started until the morning of 4/27/2014 after 0700 a.m. when the pharmacist arrived on-site and the error was detected, more than 12 hours after the medication was ordered.

Medical record review revealed P-13 was admitted on [DATE] with diagnoses that included pneumonia. A review of the hospital medication error report dated 6/7/2014 revealed P-13's physician's ordered a pharmacy consult for pharmacy to dose Vancomycin on 6/7/2014 at 8:08 p.m. The medication was not administered as ordered. The medication was not started until the morning of 6/8/2014 after 0700 a.m. when the pharmacist arrived on-site and the error was detected, more than 11 hours after the medication was ordered.

Medical record review revealed P-15 was admitted on [DATE] with diagnoses that included possible meningitis. A review of the hospital medication error report dated 7/14/ 4 revealed P-15's physician ordered Rocephin 2 grams in dextrose 5% in water 100 ml. IV piggyback on 7/14/2014 at 12:20 a.m. The medication was not administered as ordered. The medication was not started until the morning of 7/14/2014 at 9:00 a.m. when the pharmacist arrived on-site and the error was detected, more than 8 hours after the medication was ordered.

Medical record review revealed P-24 was admitted on [DATE] with diagnoses that included fever of unknown origin. A review of the hospital medication error report dated 6/8/2014 revealed P-24's physician ordered a pharmacy consult for pharmacy to dose Vancomycin on 6/8/2014 at 11:25 p.m. The medication was not administered as ordered. The medication was not started until the morning of 6/9/2014 after 0700 a.m. when the pharmacist arrived on-site and the error was detected, more than 7 hours after the medication was ordered. Medical record review revealed P-16 was admitted on [DATE] with diagnoses that included mental status charges and atrial fibrillation. A review of the hospital medication error report dated 5/19/2014 revealed P-16's physician ordered magnesium sulfate 1 G in dextrose 5% in water 50 ml IV infusion at 3:51 a.m.on the night shift. This occurred during non-pharmacist hours. The nurse supervisor filled the order in lieu of the pharmacist and the medication provided was labeled morphine sulphate. This medication error was identified as a near miss because the error was identified by the nurse at the bedside and the medication did not reach the patient

Medical record review revealed P-18 was admitted on [DATE] with diagnoses that included fracture of the C1 vertebra. A review of the hospital medication error report dated 6/1/2014 revealed P-18's physician ordered Midazolam infusion 100 mg in 100 ml of sodium chloride 0.9% 100 ml IV infusion at 2:32 a.m.on the night shift. This occurred during non-pharmacist hours. The nursing supervisor mixed the medication in pharmacy in lieu of the pharmacist and used only 20 - 25 mg in 100 ml. The concentration mixed by nursing in the pharmacy was incorrect. This medication error was identified as a near miss because the error was identified by the nurse at the bedside and the medication did not reach the patient.Pharmacy Director E, (PH-E) was interviewed on 7/17/2014 at 1:00 p.m. and stated the hospital nurse supervisors are agents of the pharmacist after hours and they have access to the pharmacy during non-pharmacist hours. PH-E stated when orders come in after the pharmacist is off-site the nurse supervisor is either to dispense the medication from the pharmacy in lieu of the pharmacist, or he/she is to call the pharmacist for dosing information. PH-E confirmed that patients P-12, P-13, P-15 and P-24 , experienced medication errors when the medications were not delivered timely during non-pharmacist hours at the time of the medication order.

Quality and Risk Manager/Registered Nurse D, (QARN-D) was interviewed on 7/17/2014 at 7:15 a.m. and stated she uses medication error reports as part of her quality review. Although the errors and near miss events had been reported, she had not identified the pattern of after hours pharmacy concerns. QARN-D stated there was no quality initiative in place to address the pattern of errors at this time.

The policy titled Adverse Health Event Policy, dated 6/7/2013 and provided by the hospital was reviewed. Under the section titled Purpose the following was observed: Adverse health events which may be defined as one or more of the following: A sentinel event, near miss, reportable event, adverse drug reaction or medication error, hazardous condition or unanticipated outcome as opposed to outcome arising from underlying disease. Adverse events are investigated to determine system or process which may have contributed to the event and systems or processes which can be identified to prevent further occurrence.
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
Based on observation, interview and document review the hospital failed to provide pharmacy services according to patient needs for 6 of 11 patients reviewed when the pharmacy was closed and patients did not receive ordered medications in a timely and/or accurate manner and failed to store dugs under competent supervision. The cumulative effect of these systems problems resulted in the hospital's inability to maintain effective pharmacy services. Therefore the hospital was unable to meet the Condition of Participation of Pharmacy Services CFR 482.25. These deficient practices had the potential to impact all patients receiving services from the hospital. These practices resulted in an immediate jeopardy to patient health and safety. Findings include:

See A-0493 - Based on interview and document review the hospital failed to ensure an adequate number of pharmacy personnel to ensure quality pharmaceutical services for 6 of 11 patient reviewed, Patient (P)-12, P-13, P-15, P-24, P-16 and P-18, who required pharmacy services during the pharmacy's closed hours and those services were not delivered timely and/or accurately.
See A - 0502 - Based on observation, interview and documentation, the hospital failed to keep all drugs and biologicals in secure a location when 2 trays of anesthesia medications were observed unattended and unsecured in an operating area hallway.
VIOLATION: PHARMACY PERSONNEL Tag No: A0493
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review the hospital failed to ensure an adequate number of pharmacy personnel to ensure quality pharmaceutical services for 6 of 11 patient reviewed, Patient (P)-12, P-13, P-15, P-24, P-16 and P-18, who required pharmacy services during the pharmacy's non-pharmacist hours and those services were not delivered timely and/or accurately. Findings include:

The policy titled Drug Removal From The Pharmacy Department During Non-Pharmacist Hours, provided by the hospital and dated revised 2/14 was reviewed. The following was observed under the section titled POLICY:

The nursing supervisor (a registered nurse) will have a key to the Pharmacy Department for access during non-pharmacist hours. Access to the pharmacy will occur only for drugs not stocked in the ED or inpatient Omnicell devices and if the drug is needed for required administration prior to the pharmacist returning to the pharmacy...The pharmacist on-call will be consulted at any time for assistance or will be called back to the hospital if necessary.

The following was observed under the section Procedure:

1. For drugs that are not available on the nursing unit Omnicell, the requesting nurse will print a copy of the eMAR screen for the drug requested and send to the Nursing Supervisor. The House Supervisor will review the order and remove the drug from the ER Omnicell and send to the nursing unit requesting the drug.

C. High risk drug orders will be reviewed with the on-call pharmacist prior to removal from the pharmacy.

2. The nursing supervisor may remove a drug from the Pharmacy Department ONLY if the drug is unavailable from the ED or inpatient unit Omnicell devices AND the drug has an emergent need to be administered prior to the pharmacist returning to the hospital.

Medical record review revealed P-12 was admitted on [DATE] with diagnoses that included sepsis. A review of the hospital medication error report dated 4/26/2014 revealed P-12's physician ordered a pharmacy consult for a pharmacist to dose Vancomycin on 4/26/2014 at 6:30 p.m. The medication was not administered as ordered. The medication was not started until the morning of 4/27/2014 after 0700 a.m. when the pharmacist arrived on-site and the error was detected, more than 12 hours after the medication was ordered.

Medical record review revealed P-13 was admitted on [DATE] with diagnoses that included pneumonia. A review of the hospital medication error report dated 6/7/2014 revealed P-13's physician ordered a pharmacy consult for a pharmacist to dose Vancomycin on 6/7/2014 at 8:08 p.m. The medication was not administered as ordered. The medication was not started until the morning of 6/8/2014 after 0700 a.m. when the pharmacist arrived on-site and the error was detected, more than 11 hours after the medication was ordered.

Medical record review revealed P-15 was admitted on [DATE] with diagnoses that included possible meningitis. A review of the hospital medication error report dated 7/14/2014 revealed P-15's physician ordered a Rocephin 2G in dextrose 5% in water 100 ml IV piggyback on 7/14/2014 at 12:20 a.m. The medication was not administered as ordered. The medication was not started until the morning of 7/14/2014 at 9:00 a.m. when the pharmacist arrived on-site and the error was detected, more than 8 hours after the medication was ordered.

Medical record review revealed P-24 was admitted on [DATE] with diagnoses that included fever of unknown origin. A review of the hospital medication error report dated 6/8/2014 revealed P-24's physician ordered a pharmacy consult for a pharmacist to dose Vancomycin on 6/8/2014 at 11:25 p.m. The medication was not administered as ordered. The medication was not started until the morning of 6/9/2014 after 0700 a.m. when the pharmacist arrived on-site and the error was detected, more than 7 hours after the medication was ordered.

Pharmacy Director E, (PH-E) was interviewed on 7/17/2014 at 1:00 p.m. and stated the hospital nurse supervisors are agents of the pharmacist after pharmacist hours and they have access to the pharmacy after hours. PH-E stated when orders come in during non-pharmacist hours, the nurse supervisor is either to dispense the medication from the pharmacy in lieu of the pharmacist, or he/she is to call the pharmacist for dosing information. PH-E confirmed that patients P-12, P-13, P-15 and P-24 , experienced medication errors when the pharmacist was not contacted and the medications were not delivered timely when medication orders were generated during non-pharmacist hours. PH-E had no explanation for why the pharmacist was not contacted for these medication orders.

Medical record review revealed P-16 was admitted on [DATE] with diagnoses that included mental status changes and atrial fibrillation. A review of the hospital medication error report dated 5/19/2014 revealed P-16's physician ordered magnesium sulfate 1 G in dextrose 5% in water 50 ml IV infusion at 3:51 a.m.on the night shift. The order was generated during non-pharmacist hours. The nurse supervisor filled the order in lieu of the pharmacist and the medication provided was labeled morphine sulphate. This medication error was identified as a near miss because the error was identified by the staff nurse at the bedside and the medication did not reach the patient

Medical record review revealed P-18 was admitted on [DATE] with diagnoses that included fracture of the C1 vertebra. A review of the hospital medication error report dated 6/1/2014 revealed P-18's physician ordered Midazolam infusion 100 mg in 100 ml of sodium chloride 0.9% 100 ml IV infusion at 2:32 a.m.on the night shift. The order was generated during non-pharmacist hours. The nursing supervisor mixed the medication in pharmacy in lieu of the pharmacist and used only 20 - 25 mg in 100 ml. The concentration mixed by the nursing supervisor in the pharmacy was incorrect. This medication error was identified as a near miss because the error was identified by the nurse at the bedside and the medication did not reach the patient.

(PH-E) was interviewed on 7/17/2014 at 1:00 p.m. PH-E confirmed that P-18's order for Midazolam is considered a high risk medication and the pharmacist should have been contacted for this medication order. He did not believe the pharmacist was contacted prior to dispensing of that medication on 6/1/14.

Registered Nurse supervisor (RN)-K was interviewed on 7/17/2014 at 10:05 a.m. and stated there is no pharmacist in the hospital at night and that approximately 2 hours out of a 12 hour shift are spent in the pharmacy mixing and pulling medications that are needed for patients in the hospital. RN-K stated she has mixed IV antibiotics including Vancomycin. She stated if the doctor orders the pharmacist to dose the Vancomyocin; she calls the on call pharmacist and the pharmacist gives her a verbal order and tells her how to mix the medication. RN-K also mixes medications for continuous IV infusion for patients in the Intensive Care Unit (ICU) such as but not limited to: Rocuronium (a neuromuscular blocking agent), Ativan, Insulin, IV fluid with added potassium, Cardizem (a cardiac antiarrhythmic medication) and IV fluids containing: Thiamine, Folic acid, multivitamin for infusion and magnesium sulfate.
PH-E was also interviewed on 7/16/2014 at 1:30 and stated the practice at the hospital includes nursing supervisors mixing IV medications as needed during non-pharmacist hours. PH-E stated the on-call pharmacist does not come in to mix IV medications, but reviews the order within 13 hours. PH-E stated nursing supervisors have one day of training in the pharmacy by a pharmacist prior to being responsible for dispensing medications during non-pharmacist hours.
The policy titled Pharmaceutical Services dated reviewed 5/12 and provided by the hospital was reviewed and revealed: Pharmacy hours of service are Monday - Friday 6:00 a.m. - 10:00 p.m., Saturday, Sunday and Holidays 7:00 a.m. - 5:30 p.m. Pharmacy needs are covered during non-professional staff hours by the nursing supervisor. A pharmacist is available, on-call, for information, questions, or to be called back to the hospital if necessary. The policy titled High Alert Medications, undated and provided by the hospital was reviewed and revealed under Specific medications: 7. Midazolam. C. New orders for drugs on this list need to be reviewed with the pharmacist prior to dispensing.

A review of the policy titled IV - IV admixture procedure, provided by the hospital and dated revised 3/14 revealed under POLICY:

The Pharmacy Department is responsible for the preparation of all IV admixture products.

Under PROCEDURE:

1. The pharmacist shall interpret all physician's orders and enter the order on the patient's pharmacy medication profile, making special note of any drug allergies...The pharmacist is also responsible for determining the compatibility of all additives and the appropriateness of all dilutions and concentrations prior to compounding and dispensing any IV medications.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation, interview and documentation, the hospital failed to keep all drugs and biologicals in secure a location when 2 trays of anesthesia medications were observed unattended and unsecured in an operating area hallway. Findings include:

During observations a wheeled cart containing 2 trays of medications were observed unsecured and unattended on 7/17/2014 at 6:55 a.m. in the surgical hallway. The Certified Registered Nurse Anesthetist (CRNA)-A was present and confirmed the cart should not be unsecured and unattended in the hallway. Each of the trays contained medications that included but was not limited to: Lidocaine, Propofol, Etomidate, Atropine, Ketorolac, Chloroprocaine, Ephedrine, Succinylcholine, Rocuronium, Oxytocin and Neostigmine.
During interview on 7/17/2014 at 11:15 a.m., CRNA-A verified that the pharmacy staff brought the cart containing the trays from the pharmacy and left it unattended in the hallway. CRNA-A stated anyone in the OR area would have had access to the unsecured medications. Pharmacy Director E, (PH-E) was interviewed on 7/16/2014 at 11:00 a.m. and stated the operating room (OR) anesthesia trays are brought to the OR on unsecured carts, but pharmacy technicians are required to stay with the carts until the trays are secured in the anesthesia work cart.
The policy titled Anesthesia Non-controlled Medication Floorstock dated reviewed 5/12 and provided by the hospital was reviewed and revealed under procedure:1. Each OR, (operating room) Suite will have one stocked medication tray secured in the top drawer of the anesthesia work cart.
VIOLATION: ANESTHESIA SERVICES Tag No: A1000
Based on interview and document review the hospital failed to provide the safe delivery of anesthesia services according to patient needs for 1 of 11 patients reviewed when the hospital did not have anesthesia medications available and no back up plan for the availabilty of medications. Therefore, the hospital was unable to meet the Condition of Participation of Anesthesia Services CFR 482.52. This deficient practice had the potential to impact all patients receiving anesthesia services from the hospital. These practices resulted in an immediate jeopardy to patient health and safety.


See A-1002-Based on interview and document review the hospital failed to provide the safe delivery of anesthesia services for 1 of 11 patients reveiwed (P1) when the hospital did not provide a Certified Registered Nurse Anesthetist (CRNA) with a functioning lock box containing medications for use in anesthesia. The lock mechanism failed to open and the CRNA was unable to access medications resulting in a deviation from procedure. This deviation from procedure resulted in a medication error in which P1 required intubation and mechanical ventilation due to respiratory failure after receving the wrong medication.
VIOLATION: PRE-ANESTHESIA EVALUATION Tag No: A1002
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review the hospital failed to provide the safe delivery of anesthesia services for 1 of 11 patients reviewed for anesthesia services (P1) when the hospital failed to provide a Certified Registered Nurse Anesthetist (CRNA) with a functioning lock box containing medications for use in anesthesia. The lock mechanism failed to open and the CRNA was unable to access medications resulting in a deviation from procedure. This deviation from procedure resulted in a medication error in which P1 required intubation and mechanical ventilation due to respiratory failure after receiving the wrong medication. Findings include:

Medical record review established P1 was admitted on [DATE] with a diagnosis of degenerative joint disease and was scheduled for hip replacement surgery.

During an interview on 7/16/2014 at 11:35 a.m., CRNA-F described as P1 was brought into the operating room (O.R.), the lock mechanism on the anesthesia narcotic box failed and he was unable to access medications. He stated as P1 was being prepared for surgery, he took the box to the pharmacy for assistance however, the box would not open. Although hospital policy required the availability of 2 boxes, the pharmacy did not supply him with a second box. He stated because of the delay due to access medications; he was rushed to get the surgery started and decided to use the medications out of the medical doctor -anesthesia (MDA) box. CRNA-F stated he drew up and administered Versed (a sedative) and Fentanyl (a narcotic) Intravenously (IV) to P1 as a precursor to getting spinal anesthesia. CRNA-F stated at that point P1 was placed in a sitting position to access the spine for the spinal anesthesia, was given the spinal anesthesia and laid back down. He stated P1 stopped talking, became rigid and stopped breathing. CRNA-F stated they were unsure what was happening at that time and they intubated P1 and started mechanical ventilation. P1 was brought to radiology for a CT scan of the brain and then to the ICU. The surgery was postponed; and CRNA-F stated he went back to the O.R. to start another case, without the anesthesia narcotic box.

CRNA-F explained the CRNA's are provided with two locked narcotic boxes however, he was provided one box because he worked part time and did not have access to a second narcotic box. He stated that each of the boxes were not standardized and set up differently according to CRNA preferences. CRNA-F stated he kept a medication called Sufenta (a potent opiate analgesic) in a small plastic bag separate from other medications in his box so it would not be mistaken for Fentanyl however, in the MDA box; the Sufenta was kept near the Fentanyl and not in a plastic bag. Both medications are in a similar or "look alike" vial.

CRNA-F stated that during the night he was trying to understand why P1 had such a strong reaction to the anesthesia and determined he may have administered Sufenta instead of Fentanyl. When CRNA-F returned to the hospital the following day, he informed his supervising physician of the possible error and discovered he did in fact administer Sufenta instead of Fentanyl and that P1 received 50 micrograms (mcg) of Sufenta which is 7 times the normal dose and much stronger than Fentanyl.

CRNA-F explained he had been on call the night before P1's surgery and had worked at the hospital until 2:00 a.m. and received four hours of sleep prior to returning to the hospital for the day shift and was feeling fatigued. He stated he thought that fatigue contributed to the medication error in addition to the lock failure, not having medications available in a second box and feeling rushed to get the surgery started.

P1's medical record was reviewed and established that P1 was extubated and breathing independently by approximately 7:00 p.m. that evening. P1 was transferred out of the ICU to a general floor and did have a successful hip replacement surgery 2 days after the incident.


On 7/16/2014 at 1:30 p.m., Pharmacist (PH)-E was interviewed and stated that each of the CRNA's have two locked narcotic boxes. He stated that one box is in use and one box is for back up so they always have medications available to them. However, PH-E verified that CRNA-F only had one box available because he job shared with another CRNA. In addition, PH-E stated that the narcotic boxes are not standardized and set up with different medications in different ways according to each CRNA preference. PH-E stated the Medical staff Performance Improvement committee approves the medications in the boxes for all CRNA's.


CRNA-A was interviewed on 7/17/2014 at 11:15 a.m. and stated if a CRNA was called in for surgery overnight; the practice was to get that CRNA's surgeries covered and send him/her home instead of allowing the CRNA to work while fatigued. He stated on the day of P1's surgery; CRNA-F had been called in overnight for an unscheduled surgery however, had not been sent home as was the normal practice. He stated a CRNA working a full day after being on-call and attending to an unscheduled surgery occurred approximately 5 times a year or less. CRNA-A confirmed that CRNA-F had been supplied with one narcotic box because he job shared with another CRNA and they had split the two boxes between them. CRNA-A stated as a result of the medication error with P1; the hospital took corrective action including: the CRNA's no longer have access to the MDA box and the Sufenta is kept in a separate plastic bag in the CRNA's locked boxes.


The hospital pharmacy policy titled Controlled Substances: Anesthesia Boxes dated 9/12 established that each Certified Registered Nurse Anesthetist (CRNA) and Anesthiologist (MDA) is supplied with two medication boxes. In addition the policy directs that the pharmacist will check used boxes comparing documented usage against remaining stock however, the policy does not specify how often this would be completed.

Pharmacist (PH)-E was re-interviewed on 7/16/2014 at 3:30 p.m. and stated that all CRNA's now have two locked narcotic boxes as of 7/1/2014 so they always have medications available to them. No policy change was made as a result of the analysis of the medication error.