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ESSENTIA HEALTH ST JOSEPH'S MEDICAL CENTER 523 NORTH 3RD STREET BRAINERD, MN 56401 March 24, 2016
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on documentation review and interviews, the hospital did not ensure medication administration policies and procedures were followed when staff failed to properly identify 1 of 11 patients (P1) whose medical records were reviewed. Findings include:

Medical record documentation notes, dated 11/20/15, filed 11/25/16 at 4:34 p.m. was reviewed. P1 presented to the Infusion Center and had blood drawn for labs. The daily schedule, Schedule for Ancillary, SJMC Infusion Therapy for 11/20/15, noted P1 treatment plan included a blood transfusion.

P1's treatment plan, dated 11/20/15, was reviewed and noted a blood transfusion to be completed. There was no order for a Neulasta injection.

Patient/Visitor Event Form, dated 11/20/15, noted P1 was erroneously given an injection of Neulasta. The root cause of P1 receiving the wrong medication was that the nurse failed to follow proper protocol. The nurse did not identify P1 per hospital protocol by asking name and date of birth.

An interview was conducted with the Chief Nursing Officer (CNO) on 3/22/16 at 12:45 p.m. and she said Nurse J/Registered Nurse (RN) called P1 who had the same first name of another patient. Nurse J made an error in the process of following patient identification for medication administration. Nurse J gave a medication to P1 instead of to the correct patient. Nurse J then determined P1 was not the correct patient.

Nurse H, Registered Nurse (RN) was interviewed on 3/24/16 at 10:25 a.m. and she said she saw P1 on 11/20/15 and stopped to say hello in P1's infusion room. P1 said he was getting an injection. Nurse knew P1 came in regularly for a blood transfusion. Nurse H walked by the work flow desk and noted lab results of a low hemoglobin for P1. Nurse H said she asked Nurse J if P1 was to be getting a blood transfusion and Nurse J said she gave P1 a Neulasta injection. Nurse H questioned whether that was the correct patient and correct medication order. Nurse H said she returned to her patients.An interview was with Nurse J on 3/23/16 at 12:30 p.m. and she stated that on 11/20/15 she checked the patient assignment, then went to the waiting room of the Infusion Center and called a patient by their first name. P1 responded and they went to an infusion room. Nurse J did not ask P1 for P1's full name and date of birth. Nurse J addressed P1 by his first name only. Nurse J checked the physician orders of a patient with the same first name. Nurse J removed a Neulasta syringe from the medication cart. Nurse J scanned P1's wrist band and the bar code from the medication bar she had taken from the medication cart. The scanning alerted Nurse J that there was no match. Nurse J assumed the name band was from a different department in the hospital and created a name band for a patient with the same first name. Nurse J did not apply this new name band to P1's wrist. Nurse J still did not verify P1's full name or date of birth. Nurse J administered an injection of Neulasta to P1 in error. Nurse J verified she did not follow the hospital policy and procedure for identifying a patient prior to medication administration.

An interview was conducted with Nurse E/Registered Nurse (RN) on 3/24/16 at 9:30 a.m. and she verified Nurse J came to her on 11/20/15 and told her a medication error occurred. Discussion of the process was conducted and the determination was made that Nurse J did not follow the hospital policy and procedure for medication administration. There was another patient with the same first name on the schedule for 11/20/15. Nurse J did not verify the full name and date of birth of P1 after they left the waiting area. When Nurse J scanned P1's name band and Neulasta medication, there was an alert. Nurse thought the alert was due to the name band from another area of the hospital. Nurse still did not verify P1's full name and date of birth. Nurse J made a new name band, using the other patient's name. Nurse J inadvertently administered a Neulasta injection to P1 who was the wrong patient. An interview was conducted with Physician I/Oncologist, on 3/23/16 at 2:40 p.m. and he said that although the medication error did occur when Nurse J administered Neulasta to P1 this did not hasten or cause P1's death.

Policy and procedure, Medication Administration Policy #700-064, last reviewed 1/15, was reviewed and noted: Procedure 8. Verify Correct Patient a. To identify a patient, ask the patient to state his or her name and date of birth and verify it matches the identification band.