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HENRY FORD HOSPITAL 2799 W GRAND BLVD DETROIT, MI 48202 Jan. 8, 2020
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and document review, the facility staff failed to administer medications to patients within accepted standards of practice in 3 (#4, #6, #9) of 5 instances observed/reviewed, resulting in the potential for less than optimal outcomes. Findings include:

On 1/7/2020 at 1014, Nurse F was observed giving intravenous (IV) medication Zofran 4 milligrams (mg) to patient #4 in the Medical Intensive Care Unit (MICU) - Pod 1. While drawing up the medication from the vial, Nurse F failed to clean the vial septum before withdrawing the medication.

On 1/7/1010 at approximately 1100, Nurse H was observed giving patient #6 Toradol 15 mg IV on the Medical Floor F-2. Nurse H failed to clean the vial septum before withdrawing the medication. Nurse H was queried if she ever cleaned the vial septum when uncapping a vial and she stated, "No."

Interview with Nurse Administrator W, on 1/7/2020 at 1105, verified that upon uncapping the vial, the septum should be wiped with alcohol before withdrawing the medication. Interview with the Chief Nursing Officer, on 1/7/2020 at approximately 1500, verified that it was expected that nursing staff were to wipe the vial septum after uncapping the vial. Review of the facility online resource was (MDS) dated [DATE] at approximately 1500 for the specific procedure of medication administration. The resource from "https://point-of-care.elsevierpermancemanager.com," titled "Medication Administration: Injection Preparation from Ampules and Vials-CE," dated/printed 1/7/2020, documented "Firmly and briskly wipe the surface of the rubber seal with an alcohol swab, being sure to apply friction and allow to dry."

On 1/7/2020 at approximately 1130, Nurse Manager K was queried about intravenous fluid administration errors in the past three months. Nurse Manager K stated that there was one error she was aware of whereby a small amount IV dextrose solution (sugar solution) was given instead of normal saline (salt solution). The error had occurred about a month ago. Nurse Manager K further stated, on 1/8/2020 at approximately 1330, that Nurse X grabbed two bags of Saline to administer to patient #9 and that she had hung the IV bag without scanning it. Nurse X was called away for about ten minutes before she scanned the bag and realized it was the wrong solution.

On 1/8/2020 at 1430, review of the facility procedure titled "Bar Code Medication Administration - # 69," dated 8/19/19, documented "After logging into the Electronic Health Record (EHR) and reaching the Patient Summary Screen, access the Electronic Medication Administration Record (eMAR) activity, then scan the patient's wristband and the patient's medication. Verify acceptance of scan on the eMAR. Administer the medications to the patient."
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
Based on interview and document review, the facility staff failed to report and/or document 1 (#9) of 4 medication errors reviewed, resulting in the potential for less than optimal outcomes. Findings include:

On 1/7/2020 at approximately 1130, Nurse Manager K was queried about intravenous fluid administration errors in the past three months. Nurse Manager K stated that there was one error she was aware of whereby a small amount IV Dextrose (sugar solution) was given instead of Normal Saline (salt solution). The error had occurred about a month ago. A request for a list of Medication Errors/Events for November 1, 2019 through January 7, 2020 and Summary of similar Medication/Fluid Events revealed that this error had not been documented. Interview with the Chief Nursing Officer on 1/8/2020 at approximately 0915 verified that it had not been documented but that "(Nurse Manager K) "wrote it up today."

On 1/8/2020 at 1200, medical record review revealed that patient #9 had an intravenous fluid order for Sodium Chloride (NaCl) 0.9% bolus 1000 milliliters on 12/8/19 at 1429, and Sodium Chloride (NaCl) 0.9% infusion continuous on 12/8/19 at 1430. Previous intravenous solution order on 12/7/19 included "Dextrose 5% and 0.45 NaCl infusion continuous."

Further interview Nurse Manager K on 1/8/2020 at approximately 1330 revealed that Nurse X grabbed two bags of Normal Saline (salt solution) to administer to patient #9 and that she had hung the IV bag on 12/8/19 without scanning it. Nurse X was called away for about ten minutes before she scanned the bag and realized it was the wrong solution. On 1/8/2020 at 1335, Nurse Manager K was queried if the error was expected to be reported to the physician and recorded as incident in their tracking system, to which she responded "Yes." Review of the electronic medical record with Nurse Manager K and Clinical Information Specialists L and V, on 1/8/2020 at approximately 1340 to 1430, revealed no documentation indicating that the physician was notified of the intravenous fluid administration error.

On 1/8/2020 at 1435, review of the facility policy titled "RL Risk: Reporting of Safety Events -# 92," dated 8/28/19, documented "Reporting a Safety Event...Reports ideally will be entered by the staff with the most knowledge of the event and within 24 hours of event discovery... Notify the Attending Senior Staff Physician..."