HospitalInspections.org

Based on review of documentation and interview, it was determined that the facility ' s governing body did not ensure that the medical staff gave quality care to all of its patients.

Findings were:

Facility policy entitled " Basic Medication Administration " stated in part " The following will be checked prior to medication administration:
? Right patient (two patient identifiers)
? Right drug
? Right dose
? Right route
? Right time

The patient ' s hospital number and name on the identification bracelet should be compared with the name and number on the Medication Administration Record (MAR) before the drugs are administered. "

On 4/20/12, Patient # 1 was administered another patient ' s medications. According to facility documentation, the nurse who administered the medications did not follow facility policy and procedure when giving medications.

In an interview with the Coordinator of Performance Improvement on 6/12/12, the above medical error was confirmed.

Based on review of documentation and interview, it was determined that the facility failed to administer medications according to facility policy.

Findings were:

Facility policy entitled " Basic Medication Administration " stated in part " The following will be checked prior to medication administration:
? Right patient (two patient identifiers)
? Right drug
? Right dose
? Right route
? Right time
The patient ' s hospital number and name on the identification bracelet should be compared with the name and number on the Medication Administration Record (MAR) before the drugs are administered. "

On 4/20/12, Patient # 1 was administered another patient ' s medications. According to facility documentation, the nurse who administered the medications did not follow facility policy and procedure when giving medications.

In an interview with the Coordinator of Performance Improvement on 6/12/12, the above medical error was confirmed.

Based on review of documentation and interview, it was determined that the facility failed to track all adverse events in its Quality Improvement meetings.

Findings were:

Facility policy entitled " Performance Improvement Plan " stated under " Objectives: "
The objectives of Trust Point Hospital are to improve the quality of patient care, enhance appropriate utilization of resources, and to reduce or eliminate unnecessary risks and hazards with in the facility by:
? Increasing the probability of desired patient outcomes by assessing and improving the processes that most affect those outcomes;
? Establishing priorities for investigation and resolution of issues and problems by addressing those with the greatest potential impact on patient outcomes and satisfaction;
? Educating employees involved in patient care in assessing and improving processes which contribute to improved outcomes;
? Educating all employees in the basic concepts of performance improvement
? Integrating medical staff performance improvement activities whenever possible with those of the organization specifically with respect to utilization review and risk management. "

Patient # 1 was given the wrong medications on 4/20/12. This adverse event had not been reported to the Coordinator of Performance Improvement until 6/12/12. The Quality Improvement team (QAI) was unaware of the event as well.

In an interview with the Chief Executive Officer and the Coordinator of Performance Improvement on 6/12/12, it was acknowledged that all adverse events should be reported to the Performance Improvement team for review and evaluation in a timely manner.