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SAINT THOMAS RUTHERFORD HOSPITAL 1700 MEDICAL CENTER PARKWAY MURFREESBORO, TN 37129 June 4, 2014
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, review of facility communications, and interview, the facility failed to have documentation of the investigation of medication errors; failed to have a documented action plan to ensure medication errors did not recur; and failed to have documentation of education provided to staff to prevent a recurrence of medication errors for one (#7) of fifteen patients reviewed.

The findings included:

Patient #7 was admitted to the facility on on July 6, 2013, with diagnoses including [DIAGNOSES REDACTED], Chest Pain, Dyspnea (difficulty breathing), Hypertension, Diabetes, Prolonged QT (EKG abnormality), and [DIAGNOSES REDACTED].

Medical record review of physician's orders (Order Sheet) dated July 6, 2013, at 11:17 p.m., revealed, "...prednisone...40 mg tab (milligram tablet)...PO (orally), QDay (every day)...Start: 07/07/13 6:00:00 (6:00 a.m.), Stop: 08/05/13 10:00:00 (10:00 a.m.)...prednisone...40 mg tab...PO (orally)...Start: 07/07/13 6:00:00 (6:00 a.m.), Stop: 07/07/13 6:00:00...prednisone...40 mg tab...PO...Start: 07/07/13 10:00:00 (10:00 a.m.), Stop: 07/07/13 10:00:00...prednisone...40 mg tab...PO...Start: 07/08/13 10:00:00, Stop: 07/08/13 10:00:00...prednisone...40 mg tab...PO...Start: 07/09/13 10:00:00, Stop: 07/09/13 10:00:00..." Further review of the physician's order sheet revealed the physician ordered Calcitonin 300 mg subcutaneous once and Avelox (antibiotic) 400 mg daily.

Medical record review of the nursing medication administration records revealed the patient received Prednisone 40 mg at 6:22 a.m., on July 7, 2014, and again at 10:14 a.m., on the same day. Continued medical record review of the medication administration record revealed the patient received Calcitonin 300 units subcutaneous at 8:00 a.m., on July 7, 2013, and again at 11:11 a.m., on the same day. Further medical record review of the nursing medication administration record revealed the patient received Avelox 400 mg on July 7, 2013, at 12:07 a.m., and again at 10:14 a.m., on the same day.

Review of a letter from the Pharmacist to the Risk Manager dated October 17, 2013, revealed the Pharmacist reviewed the medications the patient received and "...the prednisone 40 mg QDay (daily) order was electronically entered by the MD (physician) to begin at 6:00 a.m. on July 7, 2013. The first dose was scheduled at 6:00 a.m. on July 7, 2013. QDay was the scheduled frequency ordered. Because the QDay standard administration time is 10:00 a.m., the system automatically scheduled the second dose to be at 10:00 a.m. on July 7, 2013. This was not caught by the verifying pharmacist. The patient received 80 mg of prednisone that day..."

Review of a memo sent from the Director of Pharmacy in late January, 2014, revealed, "...orders placing an initial dose and the first regularly scheduled dose too close. At 6:00 a.m. an order is entered for Drug X with a daily frequency. The system schedules a dose at 8:00 a.m. and another one at 10:00 a.m. the same day. When this happens pay attention to the next administration box which should be highlighted orange. If in your clinical judgement the next dose is too early then click the 'Skip' box before you verify the order..."

Interview with the Risk Manager on June 3, 2014, at 9:00 a.m. in the Board Room, revealed the prednisone was given at 6:22 a.m., and 10:00 a.m., when it was only ordered once a day. Continued interview with the Risk Manager revealed the Medication Administration Record (MAR) printed out the order for prednisone and the nurse gave a dose at 6:22 a.m., because all orders appear on the computer. Further interview with the Risk Manager revealed the physician ordered a dose of prednisone now and then QDay but both times were put on the MAR. Continued interview with the Risk Manager revealed the pharmacy failed to pick up the error. Continued interview with the Risk Manager revealed the prednisone administration was recognized as a medication error on review by the pharmacist. Further interview with the Risk Manager revealed the pharmacist and physician did not feel the error adversely effected the patient.

Interview with the Pharmacy Supervisor on June 3, 2014, at 12:45 p.m., in the Board Room, revealed the physician entered the prednisone order and intended it to be started in the morning as a daily dose on July 8, 2013. Continued interview with the Pharmacist revealed the computer automatically scheduled a dose at 10:00 a.m., since that is standard dosing time for QDay meds. Further interview with the Pharmacist revealed the program did not pick up the two doses and scheduled a 10:00 a.m. dose for July 7, 2013, as well as the now dose ordered for 6:00 a.m. Further interview with the Pharmacist revealed staff were educated on the need to pull up the MAR as well as the med orders to compare them to see meds already given. Continued interview with the Pharmacist revealed 80 mg prednisone is still a therapeutic dose but may increase blood glucose and cause hyperactivity in that dose range.

Interview with the Risk Manager on June 3, 2014, at 12:50 p.m., and again at 3:30 p.m., in the Board Room, revealed the incident was found in October 2013; inservices were done in November 2013; and monitoring was done December 2013 to May 2014 with no errors found. Continued interview with the Risk Manager revealed no action plan was done for an incident unless there was a trend, there was harm to a patient, or there was a near miss. Further interview with the Risk Manager revealed even if an investigation is done and an action plan created, it goes into the corporate system and cannot be retrieved by the facility. Continued interview with the Risk Manager revealed most education was done in daily huddle meetings where the staff and managers meet to discuss pertinent issues on each unit. Further interview with the Risk Manager revealed there was no sign-in sheet but the staff were supposed to sign the minutes of the huddle meeting. Continued interview with the Risk Manager confirmed there was no investigation and action plan available for the incident at the facility.

COMPLAINT #