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Based on medical record review, interview and review of policy and procedures, the staff nurses incorrectly administered six doses of MS Contin (Morphine Sulfate Sustained Release) to Patient Identifier (PI) # 1 beginning 11/2/13 through 11/5/13. The hospital also failed to identify the incorrect medication when the RN (Registered Nurse) verified the physician order entered by the pharmacist and during the 24 hour chart reviews. This deficient practice effected PI # 1, one of six sampled patients.

Findings include:

Medical Record Review:

A review of the medical record reveals PI # 1 was admitted to the hospital on 10/30/13 with diagnoses to include Lumbar Stenosis and Status Post Discectomy. "The patient's pain is to be addressed and medications to be adjusted."

Physician Orders:

11/2/13: MS Contin (Morphine Sulfate Controlled Release) 30 mg (milligrams) every 12 hours (scheduled medication; not prn (as needed).)

Review of PI # 1's Medication Administration Record (MAR):

On the MAR, the order dated 11/2/13 revealed, "Morphine (MS Contin) 15 mg. oral every 12 hours - Look alike - sound alike drug *** verify ***." No entry was seen on the MAR for MS Contin 30 mg. every 12 hours (scheduled).


PI # 1's MAR, dated 10/13/13 through 11/8/13, was reviewed by the surveyor on 3/21/14. PI # 1 was given six doses of MS Contin (Morphine Sulfate Controlled Release) 15 milligrams on the following dates/times:

1). 11/2/13 at 20:50;

2) 11/3/13 at 08:00;

3) 11/3/13 at 20:30;

4) 11/4/13 at 07:55;

5) 11/4/13 at 19:30 and

6) 11/5/13 at 07:25.


Interviews:

During an interview on 3/21/14 at 11:30 AM, the CNO (Chief Nursing Officer/ EI # 2) reviewed PI # 1's medical record and was unable to find an order for MS Contin 15 mg dated after 10/30/13.

During an interview on 3/21/14 at 1:00 PM, the Director of Pharmacy/ Employee Identifier (EI ) # 1 said, "Appears to have been an error. The order for 30 milligrams MS Contin, written on 11/2/13, was entered into the system as MS Contin 15 milligrams with the intention of having the patient take two (15 milligram) tablets." The order was entered incorrectly as 15 milligrams and the pharmacist failed to write a comment to give two 15 milligram tablets to equal 30 milligrams. "The pharmacist entered in error. It was caught on 11/5/13 and the order was discontinued."


Policies and Procedures:

"Title: Medication Administration
Revised/Reviewed: 1/2013

Policy: It is the policy of Hospital # 1 to provide guidelines for safe administration and documentation of medications and guidance for reporting adverse medication events.

Procedure:
...6. Prior to administering medications, always confirm the "5 rights" of medication administration...:
a. Right Dose
b. Right Medication
c. Right Patient
d. Right Time
e. Right Route...

Medication Administration Record:
...2. Nurse Verification of Medication Orders entered by Pharmacy:
...Process when order is not correct
- Notify Pharmacy
- Procedure: If Pharmacy is closed when error is noted the Nurse should not verify order...
- Process of Verification and notation:
- RN's and LPN's (Licensed Practical Nurse) verify Physician Orders
- After order has been faxed...the chart tab will be flagged for Nursing to verify the order.

Medication Errors and Near Misses:

1. Medication Near Miss or Preventable Drug Event is defined as an event that may be anticipated and/or forestalled and that will cause or lead to inappropriate medication use or patient harm...

2. ...Medication for Reporting forms are forwarded to the Nursing Supervisor/Nurse Manager for follow up. "Near Miss" reporting is a non-punitive report that is used to address flaws with medication administration system..."


Title: Charts - 24 Hour Chart Review
Revised/Reviewed: 2/2010

"Policy: It is the policy of Hospital # 1 to provide a mechanism to ensure timely and accurate nursing documentation and execution of physician orders.

Responsibility:
A. It is the responsibility of the licensed nursing personnel on the 11-7 shift to complete the chart review...

Procedure:
A. Review all orders written for previous 24 hours to ensure transcription in the Meds/MAR and Kardex system.
1. Medications are properly entered into the Meds/MAR System. Check for correct drug, route, dose time and patient...
C. Twenty-four hour checks must be signed, dated and timed indicating the last order written when reviewed..."

All of the 24 hour checks in PI # 1's medical record were done and signed by the RN indicating all of the physician orders had been verified as correct.

The medication error was not identified by the hospital's usual practices of nurse verification of the order entered by the pharmacy on 11/2/13 or during 24 hour chart checks. As a result, PI # 1 was given six incorrect doses of MS Contin. There was no evidence based on interviews and document reviews to indicate that the incident was analyzed and communicated with other departments to help prevent a reoccurrence.

Based on interviews, medical record review and review of the document, "Director of Pharmacy's Process when Pharmacist Medication Errors are Identified" the Pharmacist failed to correctly enter the physician order dated 11/2/13 for MS Contin 30 (Morphine Sulfate Controlled Release) milligrams. As a result of the error, Patient Identifier (PI ) # 1 received six incorrect doses of MS Contin 15 milligrams (mg). This deficient practice affected PI # 1, one of six sampled patients.

Findings include:

A review of PI # 1's medical record revealed a Physician's Order was written on 11/2/13 for MS Contin 30 mg every 12 hours.

A review of the "7 Day Medication Administration Record " (MAR) reveals an order was entered electronically on 11/2/13 for Morphine (MS Contin - Morphine Sulfate Controlled Release) 15 milligrams oral every 12 hours to be given at 08:00 and 20:00. No entry was seen on the MAR for MS Contin 30 mg. every 12 hours (scheduled).

MS Contin 15 milligrams oral was incorrectly administered six times because the order was entered incorrectly (not as written by the physician) for 15 milligrams instead of 30 milligrams on the following dates:
11/2/13 at 20:50
11/3/13 at 08:00 and 20:30
11/4/13 at 07:55 and 19:30
11/5/13 at 07:25.


During an interview on 3/21/14 at 1:00 PM, the Director of Pharmacy/ Employee Identifier (EI ) # 1 said, "Appears to have been an error. The order for 30 milligrams MS Contin, written on 11/2/13, was entered into the system as MS Contin 15 milligrams with the intention of having the patient take two (15 milligram) tablets." The order was entered incorrectly as 15 milligrams and the pharmacist failed to write a comment to give two 15 milligram tablets to equal 30 milligrams. "The pharmacist entered in error. It was caught on 11/5/13 and the order was discontinued."


According to the document titled, "Director of Pharmacy's Process when Pharmacist medication errors are identified, dated 3/26/14, the Director of Pharmacy:
- Investigates the medication error by reviewing the order and comparing the order to what was entered into the medication system
- Investigates which Pharmacist is responsible for the medication error; and what error the Pharmacist made
- Motilities the Pharmacist who made the error
- Tracks Pharmacist medication errors
- If a medication error is a near miss or has not caused any harm to the patient, the Director of Pharmacy notifies the Pharmacist of the error, instructs the Pharmacist to pay closer attention, and tracks the Pharmacist medication errors
- Does verbal counseling as needed
- If egregious harm is done to the patient, the Director of Pharmacy obtains Human Resources involvement..."