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.

ST JOSEPHS COMMUNITY HOSPITAL OF WEST BEND 3200 PLEASANT VALLEY ROAD WEST BEND, WI 53095 Feb. 18, 2013
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview and record review, the hospital failed to ensure that aggregate medication error data collected was used to identify opportunities for improvement. This occurred in 2 of 2 interviews (on 2/6/13 and 2/11/13 ) with the staff pharmacist. This has the potential to effect the total population of 60 patients.

Findings include:

In interview with Pharmacist F on 2/6/13 at approximately 1:20 p.m., this pharmacist stated that when a nurse computer scans a medication using the manufacturer's bar code, that the medication computer's system does not notify the nurse of the potential to have the wrong patient name. Pharmacist F states that the medication scanner does alarm if the medication, dose, route and time are right. Pharmacist F states that when medications are mixed by pharmacy staff, and a bar code is produced by the hospital pharmacy that it alarms for patient name, medication, dosage, route and time. Pharmacist F states that it is the nurse's responsibility to ensure he/she has the right patient name when using manufacturing bar codes. Pharmacist F stated that he is aware of the medication occurrence report for Patient #1, in which Patient #1 was given an IV (intravenous) antibiotic labeled with Patient #2's name. Pharmacist F states that this IV antibiotic is administered through the manufacturer's bar coding system. (Reference 0405)

Pharmacist F stated in interview on 2/11/13 at approximately 1:10 p.m. that he could not define how many occurrences of "wrong patient" doses were made by nursing staff over the past 12 month period, and whether they were tied to the manufacturer's computer coding processes. Pharmacist F states that he does not track or trend this type of information for quality improvement purposes.

The 2/11/13 review of "Medication Events from Feb. 2012 through [DATE] reflects that there are 286 occurrence events logged. There is no documented evidence that Pharmacist F evaluated this adverse occurrence data for nursing administration trends and patterns to see if opportunities for improvement were possible.

This above information was shared in interview with Nursing Executive E on 2/11/13 at approximately 2:30 p.m. As of 2/18/13, information sent by Nursing Executive E information did not show documented evidence of the above process.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on hospital staff interview, patient interview and medical record review, the hospital failed to ensure that 1 of 4 patients (Patient #1) had medications administered according to current nursing practice standards and hospital policy. This has the potential to affect the total hospital population of 60 patients.

Findings include:

In interview with Patient Care Director (PCD) E and Registered Nurse (RN) D on 2/11/13 at approximately 7:45 a.m. RN D stated that she gave Patient #1 an IV antibiotic medication labeled and intended for Patient #2. Patient #1 received intravenous (IV) antibiotic Vancomycin 1000 mg. in 200 ml. of fluid. RN D stated that the antibiotic medication, medication dosage, method given and the time given were correct, but the name on the IV bag was for another patient. RN D stated that she told Patient #1 he got the right medication, even though it was not labeled with his name. RN D stated that she knew this was a medication error for not having the correct patient, and that this was against hospital policy and nursing medication standards of practice. In interview with PCD E, at the time above, PCD E stated that RN D filled out a medication error occurrence report and filed it with the hospital.

In interview with Pharmacist F on 2/11/13 at approximately 1:10 p.m., pharmacist states what information was disclosed to Patient #1, when the pharmacist reprinted Patient #2's medication label. The 2/11/13 review of this label at approximately 1:10 p.m. reflects that it has patient name, room number, name of medication, dosage and use directions.

In interview with Patient #1 on 2/15/13 at approximately 11:45 a.m., Patient #1 states he has pictures of Patient #2's medication label information. Patient #1 stated that this information was noted when he inspected the medication that was currently infusing in his IV bag. Patient #1 stated that the nurse was contacted immediately because Patient #1 thought that medication was wrong. The 2/15/13 review of Patient #1's four (4) pictures at approximately 11:45 a.m., reflects that he has Patient #2's information the the photographed IV bag.

Nursing Executive E confirmed these findings on 2/11/13 at approximately 3 p.m. and had no additional information.