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GEISINGER-LEWISTOWN HOSPITAL 400 HIGHLAND AVENUE LEWISTOWN, PA 17044 April 9, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on a review of medical record (MR), facility documents and interview with facility staff (EMP) it was determined that Geisinger Lewistown failed to follow adopted policies to ensure that the patient/family was educated on a new medication prior to administration of the first dose in one of one medial record (MR1).

Findings Include:

Nursing Manual ... Geisinger ... Policy 11.02 ... 11.0 Medication Management ... Medication Administration (System) policy dated January 20, 2018. "Purpose: The purpose of the Medication Administration policy is to ensure the patient will receive ordered medications in a safe and therapeutic manner. Persons Affected: Hospital and Clinical staff responsible for administering medications. Policy: Geisinger will follow the following process for medication administration. ... 11. Advise the patient or if appropriate the family about any potential clinically significant adverse reactions or concerns about administering a new medication. ... ."

Geisinger Administrative/Clinical Policy and Procedure Manual ... Policy 10.433 ... 10.0 Provision of Care, Treatment and Services ... Title: Education for Patient/Family dated October 23, 2017. "Purpose: The purpose of the Education-Patient/Family policy is to promote the documentation of learning needs and provide access to high quality patient educational materials and resources relevant to each individual's needs and preferences based on cultural values, religious beliefs, emotional barriers, desire and motivations to learn, physical and/or cognitive limitations, and language barriers. The goal is to increase patient/family comprehension and participation in the self-management of healthcare needs. Policy: Patient education is an integral component of the patient care provided within Geisinger Health System. Patient/family education is an interdisciplinary and collaborative process designed to meet the needs of the individual patient throughout the continuum of care. The patient/family/significant others play an active part in the process. ... Process: 1. Each patient will have his/her educational needs and learning preferences evaluated by the appropriate discipline ... 4. The Educational Learning Needs Assessment is found in the medical record. This documentation shall be a permanent part of the patient's medical record. Documentation of patient education should correspond with the patient's individualized needs and plan of care. ... Inpatient RN Patient Education and Documentation Responsibilities: Assess the educational needs of the patient and formulate a plan of care to meet the educational needs. Initiate new educational topics. Utilize the use of teach back questions contained in each educational topic to assess patient/family learning. ... ."

1. MR1 failed to reveal documented evidence that inpatient medication education related to Guanfacine was conducted prior to administration of the first dose following the physician order dated February 10, 2018 at 10:00 PM.

EMP4 reviewed MR1 with surveyor on April 3, 2018, at approximately 2:00 PM. EMP4 stated, "It doesn't look like patient education was done prior to the Guanfacine being given."
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on a review of facility documents, medical records(MR), and staff interviews(EMP), it was determined that Geisinger Lewistown failed to take steps to prevent, identify, and minimize drug errors through standardization of prescribing and communication practices to include: but not limited to, alert systems for look-like and sound-alike drug names for one of one medical record reviewed. (MR1)

Findings include:

Geisinger Policy 11.207 Section 11.0 Medication Management Title Look-Alike/Sound-Alike Medications, dated April 19, 2017. "Purpose: To enhance patient safety by decreasing medication errors through education and identification of look-alike/sound-alike medications. Individuals responsible for preparing, dispensing and administering medications are affected by this policy. Policy: It is the policy of Enterprise Pharmacy to ensure that persons responsible for preparing and administering medications are made aware of medications that either look alike or sound alike, in an effort to reduce the occurrence of medications. ... Responsibilities: Individuals involved in the preparing, dispensing and administering medications are responsible for complying with the contents of this policy. ... Procedure: A. Identify and develop an appropriate list of medications that either look-alike or sound - alike (See Look-Alike/Sound-Alike Risk List - Exhibit A). ... D. The Look-Alike/Sound-Alike Risk List will be sent to the Nursing Educators to be posted in each inpatient care area and clinic. E. The Pharmacy and Nursing Staff will be educated regarding the look-alike/sound alike medication safety issue and methods for preventing errors. F. The Pharmacy information system will utilize tall-man lettering for parts of the names that are different to assist with the identification of look-alike/sound-alike medication by both Pharmacy and Nursing personnel. G. As medications are reviewed by the System Formulary Steering Committee for addition to the formulary, potential medication error issues will be reviewed and documented. ... K. The look-alike/sound alike list will be reviewed annually by the Medication Safety Workgroup and will be responsible for approval of all revisions. ... Exhibit A Geisinger Health System Pharmacy Look-Alike / Sound-Alike Risk List ... ."


1. Policy:11.207 - Exhibit A, which is the Geisinger Health System, Pharmacy Look-Alike/Sound-Alike Risk List revealed that neither guanfacine or guaifenesin was included on the list.


2. MR1 revealed a Medication Order "... GuanFACINE HCL (TENEX) tab 1 mg ... Ordered Dose:1 mg
Route: Oral
Frequency: QHS
Priority: Routine.
Administration Dose:1mg.
Start: 02/10/18 at 2200 ... Ordering User: EMP10 ... ."


An interview with EMP10 was conducted on April 4, 2018, 11:30 AM. "... I wanted to order the patient something for their cough, the patient told me did not like liquid cough syrup. Someone told me there was a pill form of guaifenesin, I cannot remember who it was that told me. I wanted to order the pill form of the cough syrup. ... I typed in gua, and 3 drugs came up on the medication list. I saw the first 2 were syrup and the last one was po tabs, I picked the po tabs. I didn't realize the drug name had switched from Guaifenesin to Guanfacine."


3. Facility documentation provided on April 6, 2018, revealed an image of the drop down box that the physician would see when selecting medications and/or treatments. The following popped up:
"guaiFENesin-codeine (Robitussin AC)
Robitussin DM (guaiFENesin-dm) syrup
GUANFACINE HCL 1mg PO tabs ..."

An interview with EMP3 was conducted on April 4, 2018, at 1:40 PM. "There is no requirement for the number of characters that a physician is required to enter when typing in a medication before the choices populate, there is also no alert or warning that pops up for sound alike meds, and there is no hard stop on the computer when ordering sound alike medications."

4. Further review of MR1 medication orders revealed that a Warning of possible drug interactions with GUANFACINE and two of the patients's current medications appeared on February 10, 2018, and were overridden by EMP9.
Additionally, at discharge a Warning for Duplicate Therapy (GUANFACINE) for Antihypertensives that was overrridden by the Pharmacy.

An interview was conducted with EMP3 on April 3 at approximately 1:00 PM. "Guanfacine use is only approved for patients 17 years and older. This patient's blood pressure was off the charts and it would be expected that the physician would reach for an antihypertensive. The doctor had the patient on Tessalon so I would not expect them to order guaifenesin as well, one or the other. EMP3 verified with the Pharmacy that the only form available at the facility for po guaifenesin was liquid form. ... We do not require the physician to include a reason when they order a drug that is new for a patient."

An interview was conducted with EMP9 on April 4, 2018, at 10:30 AM. "When we override a warning, there are many things that we look at. Correct dose, route, frequency, indications, renal function, sex of patient. Sometimes the indication is not as clear as others, but if the patient's blood pressure was up, then it was reasonable to me for that the physician would order it. I believe there was an override because there was a drug interaction indicated with the ... , which could cause added drowsiness. The physician can see an override if they look for it, then they choose the reason why they want to override. ... We used to have a speed code with five characters, now we only have three. To type a little more would be better, safer, but it's the physician's decision which med to choose. We can still always call the doctor, but we try to figure it out on our own."