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Based on interview and record review, the facility failed to ensure the nursing staff followed the pre-printed heparin (a medication used to treat and prevent blood clots) order set (an order used for standardizing a provider order entry following an evidence-based practice) when the nursing staff did not follow the heparin's rate adjustment order for one of 31 sampled patients (Patient 6).

This failure had resulted in a preventable medication error which could potentially lead to excessive bleeding with unsafe medication administration and negatively affect Patient 6's health and safety with prolonged hospitalization, and/or lead up to death.

Findings:

During a review of Patient 6's "History and Physical (H&P)," dated May 14, 2022, at 10:10 AM, the H&P indicated, Patient 6 was admitted into the facility with diagnoses including sepsis (severe infection), respiratory failure (a condition when lungs cannot get enough oxygen), status post tracheotomy (surgical procedure which creates a direct airway to the trachea), encephalopathy (a condition of brain damage), and right thigh hematoma (a collection of blood outside the blood vessel).

A review of Patient 6's "Intravenous (IV-into the vein) Heparin by Weight Order set," dated May 22, 2022, at 10:15 AM, indicated, Heparin was ordered to be started at 18 units per kilogram per hour (units/kg/hr-unit dosing of medication) with the dosing weight of 80 kg, and titrate (adjust) heparin based on the Activated Partial Thromboplastin Time (APTT-a blood test to measure the time it takes for a blood clot to form). The "Intravenous Heparin by Weight Order set" indicated as follow:

APTT less than 38 seconds: increase heparin drip by 4 units/kg/hr
APTT 38 to 44 seconds: increase heparin drip by 2 units/kg/hr
APTT 45 to 79 seconds: no rate change
APTT 80 to 95 seconds: decrease heparin drip by 2 units/kg/hr
APTT greater than 95 seconds: hold the heparin drip for one hour, then decrease heparin drip by 3 units/kg/hr

During a concurrent interview and record review, on May 25, 2022, at 9 AM, in the conference room, with the Director of Pharmacy (DOP) and the Director of Nursing 1 (DON 1), Patient 6's "Heparin Monitoring Flowsheet," dated May 22, 2022, at 10:30 AM, through May 25, 2022, at 11:50 AM, was reviewed. The "Heparin Monitoring Flowsheet" indicated as follow:

On May 23, 2022, at 4:25 AM, indicated, the APTT result was 45.10 seconds with the current heparin running at 20 units/kg/hr and new rate set at 22 units/kg/hr. The nursing staff increased the new rate by 2 units/kg/hr.

The DOP verified and confirmed, the heparin was increased by 2 units/kg/hr with the APTT result of 45.10 seconds. The DOP stated, the nursing staff should not have changed the heparin dosage based on the APTT result.

A follow-up interview, on May 25, 2022, at 9:08 AM, with the DON 1, stated, the inappropriate heparin dosage adjustment increased the risk of bleeding for Patient 6.

During an interview, on May 25, 2022, at 5 PM, with Registered Nurse 7 (RN 7) and the DON 1, RN 7 stated, the nursing staff needs to follow the order set and/or heparin protocol based on APTT results for any heparin initial rate and dosage adjustment.

A follow-up concurrent interview and record review, on May 25, 2022, at 5:25 PM, with RN 7 and the DON 1, Patient 6's "Heparin Monitoring Flowsheet," dated May 22, 2022, at 10:30 AM, through May 25, 2022, at 11:50 AM, was reviewed. The "Heparin Monitoring Flowsheet" indicated as follow:

On May 23, 2022, at 4:25 AM, indicated, the APTT result was 45.10 seconds with the current heparin running at 20 units/kg/hr and new rate set at 22 units/kg/hr. The nursing staff increased the new rate by 2 units/kg/hr.

RN 7 verified and confirmed, the heparin was increased by 2 units/kg/hr with the APTT result of 45.10 seconds. RN 7 stated, the nursing staff did not follow the heparin order set during the heparin dosage adjustment.

A review of Patient 6's "Test reported," dated on May 23, 2022, at 11:40 AM, indicated, the APTT result was 80.20 seconds.

A review of the facility's P&P titled, "Core: Heparin Infusion Protocol," release date June 2019, indicated as follow:

"Purpose: this policy establishes guidelines for the safe and efficacious management of continuous intravenous unfractionated heparin. This policy facilitates achieving rapid therapeutic anticoagulation with heparin into the target activated partial thromboplastin time (aPTT) ...
Policy: the policy of [Hospital Name] is to ensure the following
1. The heparin infusion protocol will be based on a pre-established dosing guideline approved through the Pharmacy & Therapeutics (P&T) Committee under the authority of the Medical Executive Committee ...
3. Heparin infusions will be infused on a programmable IV pump: Verify each dose adjustment/change with a second licensed healthcare professional. Documentation of this verification will be in the medical record ..."