HospitalInspections.org

Based on interview and document review, the hospital failed to ensure that all staff comply with nationally recognized guidelines and the hospital policy for the appropriate opening and discarding dates for multi-dose vials.

Findings:

During a tour of the Emergency Department on 10/23/17 at 2pm, several nursing staff were queried about the amount of time a multi-dose vial may remain in use after it is open. The unanimous response was 90 days. The nursing staff who were queried included an Emergency Department RN and the Emergency Department Nurse Manager. The Nursing Educator (Staff B) was also present.

Review of policy "Medication Storage", effective 10/19/15, reviewed and revised 10/7/17," Multiple Dose vials", p6, on 10/24/17 at 11am, the policy states that open multi-dose vials are to be discarded after 28 days. This information was verified by the Chief Nursing Officer on 10/24/17 (Staff A).