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NOVANT HEALTH FORSYTH MEDICAL CENTER 3333 SILAS CREEK PARKWAY WINSTON-SALEM, NC 27103 June 7, 2018
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, and staff interviews the hospital nursing staff failed to follow policies and procedures for administration of intravenous (IV) medications by failing to properly scan, label tubing and trace IV lines for 1 of 1 IV Oxytocin (Pitocin, causes contractions, can be used to induce labor) medication errors. (Pt #7)

The findings include:

Review of the policy "Oxytocin administration during labor and delivery", revised 02/16/2018 from Lippincott Procedures, and provided as hospital policy on 06/06/2018, revealed " ...Implementation ....If your facility uses bar-code technology, scan your identification badge, the patient's identification bracelet, and the medication's bar code ....Connect the IV administration set tubing to the electronic infusion device following the manufacturer's instructions. Set the infusion rate as ordered .....Trace the IV administration set tubing from the patient to the point of origin to ensure that you're connecting the tubing to the correct port.... If you'll be using multiple IV lines, label the tubing at the distal (near the patient connection) and the proximal (near the source container) ends to reduce the risk of misconnection ....Special Considerations ....The Joint Commission has issued a sentinel event alert ....be sure to trace the tubing and catheter from the patient to the point of origin before connecting or reconnecting any device or infusion, at any care transition ....and as part of the handoff process ...When different access sites exist or several bags are hanging, label the tubing at the distal and proximal ends. ..."

Review of policy titled "Intravenous Therapy Management for Pediatric and Adult Patients", dated 08/15/2015, revealed " ...B. Infusion Equipment ....3. Infusion pump drug library will be used unless the drug and/or concentration is not listed or drug library is not available. 4. Verify correct infusion pump setting, fluid, and IV insertion/dressing date with each caregiver handoff ....8 .....b) Trace the administration set from patient to point of origin before attaching the device. ..."

Medical Record review, on 06/05-06/2018, revealed Patient #7, a 32 year old, was admitted on [DATE]. The History and Physical (H&P), dated 05/14/2018 at 1605, stated Patient #7 had chronic hypertension [high blood pressure {BP}] with "likely superimposed preeclampsia" [pregnancy complication with high BP]. Review revealed Patient #7 presented to "clinic" on 05/14/2018 with complaints of headache and significantly elevated BP and was sent to the hospital for induction of labor. Review of a Flowsheet, dated 05/14/2018 at 1600, revealed a physician order for Pitocin [can cause or strengthen contractions] 30 units in 500 milliliters (ml) of Sodium Chloride 0.9% [Normal Saline]. At 1602 an order was documented for magnesium sulfate [to treat blood pressure] and Lactated Ringers [LR, type of intravenous {IV} solution] to be given IV. Flowsheet review revealed a bag of Magnesium sulfate in 500 ml fluid was hung at 1652 and a bag of LR was hung at 1654. At 1655, "Medication Hold" was documented along with "oxytocin (PITOCIN) 30 units in NACL 0.9% 500 mL - premix- Dose: 0 milli-units/min [minute]; Rate: 0 mL/hr; Route: IntraVENous; Reason: Not applicable; Scheduled time: 1530." Flowsheet review then revealed, at 1655, "...Pitocin: Start..." Flowsheet review did not reveal the dose of Pitocin that was started. At 1728, Flowsheet review revealed "...reviewed by [physician initials]; requested RN cut back pit [Pitocin] from 4 to 2... ." Review at 1730 revealed the fetal heart rate was 125 baseline, with moderate variability, accelerations present, and variable decelerations. Review revealed contractions were every 1-2 minutes with duration of 70-100 seconds. Record review revealed "pit at 2" was documented at 1731. At 1758, the RN noted "Pitocin: Stop". Review of Flowsheets, at 1904, revealed "Nurse to Nurse Report" was given. A Physician Progress Note, timed at 2157, stated "Pit off now; has not been restarted since night RN turned it off due to tachysystole [excessively frequent uterine contractions].... Review of a Progress Note, dated 05/15/2018 at 0653, revealed "Labor & Delivery summary - In review of pt's chart and discussion with RNs, it was brought to my attention that pitocin had been running at 75 ml/h, instead of the LR (LR had actually be [sic] shut off instead of pit). By [approximately] 930pm, RN discovered this medication error, and pit was shut off. MD was notified at this time. ..." Review revealed a male infant was delivered by cesarean section at on 05/15/2018 at 0444 with Apgar scores of 8 at one minute and 9 at five minutes. Further review revealed Patient #7 was discharged on [DATE].

Interview with RN #3, on 06/06/2018 at 1345, revealed she cared for Patient #7 on 05/14/2018 and started the Pitocin. Interview revealed RN #3 was aware of the policies and processes to follow. RN #3 stated her usual practice was to scan to connect the patient, pump and computer, to label the tubing and trace the lines. Interview revealed RN #3 recalled she did not label the Pitocin tubing because there was not a label readily available in the area at the time. As far as the other processes, RN #3 stated she did not recall specifically, but in her mind she followed the normal processes. Interview revealed she reported to RN #4 the tubing was not labeled who said she would label the tubing. RN #3 stated she noted the Pitocin start on the fetal monitor strip. Interview revealed the details of the order and the Pitocin start should have been documented in the record, but were not there. RN #3 further stated that per her recollection and note on the monitor strip she decreased the Pitocin to 2 and then discontinued it per physician order. When she got off duty, RN #3 stated, she thought the Pitocin was off and was later notified about it. Interview revealed RN #3 could not explain what happened.

Interview with RN #4, on 06/06/2017 at 0930, revealed she worked nights on 05/14/2018 and cared for Patient #7. Interview revealed the nurse going off duty (RN #3) reported the Pitocin was started around 1600 but had since been turned off. Interview revealed they did not trace the lines during report. Interview revealed RN #4 went into the room shortly after report and observed the monitor strip and the baby looked "great". RN #4 said she glanced at the IV's and thought they looked okay but did not trace the lines or label the IV's at that time. When she went in later to hang a fluid bolus, RN #4 stated, she traced the IV lines, and noticed the Pitocin had not been cut off, the regular IV fluid was what had been discontinued. RN #4 stated when she realized this, at around 2120, she immediately cut the Pitocin off and informed the Charge Nurse. Interview revealed the physician came to the bedside, evaluated the patient, and disclosed to the patient and family what had happened.

Interview with the Director of Women and Children Services, on 06/07/2018 at 1155, revealed policies are in place to guide practice. Interview revealed policies were not followed.

NC 312, NC 540