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Based on record review and interviews, the facility did not develop, implement and maintain an effective on-going data driven quality assessment and performance improvement program in that the action plans derived from the root cause analysis did not identify opportunities for the prevention and reduction of medical errors for 1 of patient (Patient #1) who received Diprivan.
1. Patient #1 received 10mg/minute of Diprivan instead of 10 mcg (microgram)/ minute of Diprivan;
2. The physician used an unapproved abbreviation; and
3. The pharmacy did not correctly interpret the physician's order and mislabeled the medication bottle.

Cross Refer to Tag A0276

Based on record review and interviews, the facility's CNO (chief nursing officer) did not demonstrate responsibility with regards to the adverse event dated 07/23/10 for the following, citing 1 of 1 patient (Patient #1) who received Diprivan:
1) There was no policy for Diprivan use in the "HOU" (High Observation Unit);
2) The physician order was not verified;
3) There was no appropriate infusion equipment to deliver the Diprivan in micrgrams; and
4) Prior to administration of Diprivan, the Registered Nurse did not have knowledge of the drug's dose range as required by the facility's policy.

Cross Refer to Tag A0405

Based on record review and interviews, the facility's Director of Pharmacy did not demonstrate competent supervision with regards to the adverse event dated 07/23/10 for the following, citing 1 of 1 patient (Patient #1) who received Diprivan:
1) There was no policy for Diprivan use in the "HOU" (High Observation Unit);
2) The physician order was not verified;
3) The Diprivan bottle was mislabeled; and
3) There was no appropriate infusion equipment to deliver the Diprivan in micrograms as ordered by the physician.

Cross Refer to Tag A0500

Based on record review and interviews, the facility's pharmacist did not provide patient safety in that 1) Diprivan was dispensed for patient use and did not provide the accurate dosage, 2) there was no infusion pump available to deliver the Diprivan as ordered by the physician, and there was no policy for Diprivan usage at the time of the adverse event on 07/23/10, citing 1 of 1 patient who received Diprivan.

Findings:

Patient #1 was admitted on 07/19/10 for "right upper left pulmonary embolism." On 07/22/10 at 2130, the patient was intubated by Physician #1. On 07/23/10 at 1020, Physician #2 ordered "Diprivan drip - begin 10 ug/ min - call for agitation." The physician's abbreviation of "ug" was not legible and "ug" abbreviation was not to be used per facility's protocol. The pharmacist initially dispensed Diprivan 10 mg/ ml (100 ml) in which the dosage was incorrectly labeled as to how much to infused in milliliters/ minute.

In an interview the morning of 08/31/10 and the morning of 09/02/10 via phone, the Director of Pharmacy (Personnel #2) was asked what he wrote in the initial label of Diprivan. Personnel #2 stated that he labeled the Diprivan "1 mg/ hour." Personnel #2 was asked if there was a Diprivan policy in place during the time of Patient #1's adverse event. Personnel #2 stated that there was none.

Policy: "General Dispensing of Medications" effective date 08/24/08 required "The purpose of this policy is to provide guidelines to be followed for the safety of dispensing any medication from the pharmacy...Review of Original or Direct Copy of Order by a Pharmacist a. A pharmacist shall review the practitioner order, before the initial dose is dispensed..."

Policy: "Dispensing Containers and Labels" effective date 08/24/08 required "All drugs used in the facility shall be ...appropriately labeled...All labels shall include...drug strength...dosage..."

Based on record review and interviews, the facility did not identify opportunities for improvement and changes that will lead to improvement for physician and pharmacy services with regards to the the adverse event identified on 07/23/10, citing 1 of 1 patient (Patient 1) who received Diprivan.

Findings:

Patient #1 was admitted on 07/19/10 for "right upper left pulmonary embolism." On 07/22/10 at 2130, the patient was intubated by Physician #1. On 07/23/10 at 1020, Physician #2 ordered "Diprivan drip - begin 10 ug/ min - call for agitation." The physician's abbreviation of "ug" which stands for microgram was not legible. The RN (registered nurse) administered Diprivan drip 10 mg/ minute for approximately 1-1/2 hours. The patient received a total of 100,000 mcg instead of the ordered 600 mcg/minute.

"Root Cause Analysis & Action Plan" completed on 07/26/10 showed that this incident was considered a "near-miss." The action plan did not identify the following: 1) Physicians and other health care providers shall not use abbreviations for micrograms as required and handwriting should be legible. 2) Developing Diprivan pharmacy and nursing guidelines. And, 3) No accurate drug dosage labelling by the pharmacist.

The "Do Not Use Abbreviations" protocol, no date, included not to write the "ug" abbreviation but to write "mcg" or "micrograms."

Policy: "...Performance Improvement" date 01/01/09 required "It is the policy of this hospital to continuously monitor and improve the performance of all staff members who provide patient care services."

In an interview the morning of 08/30/10, the CNO (chief nursing officer/ Personnel #1) was asked if an incident report was completed. She stated "yes" and stated that a root cause analysis was also completed. Personnel #1 was asked why the "action plans" in the root cause analysis did not include the identification of performance improvement on the physician and pharmacy services. Personnel #1 stated that she did not know. Personnel #1 was asked if she was present when Personnel #4 checked the order. She stated "yes." Personnel #1 stated that the charge nurse (Personnel #5) was also present.

In an interview the morning of 08/30/10, the Registered Nurse (RN) (Personnel #4) was asked why he did not verify the physician's Diprivan order. The RN replied that he "was sure that the order read mg (milligrams) and that 2 other nurses (CNO/Personnel #1 & Personnel #5) where present to confirm the order. Personnel #4 was asked if the facility had an infusion pump that could deliver microgram rates. Personnel #4 stated "no" which was confirmed by the CNO later that morning (08/30/10). The CNO stated that she just ordered the pump.

In an interview the morning of 08/31/10 and the morning of 09/02/10 via phone, the Director of Pharmacy (Personnel #2) was asked what he wrote in the initial label of Diprivan. Personnel #2 stated that he labeled the Diprivan "1 mg/ hour." Personnel #2 was asked if there was a Diprivan policy in place at the time of Patient #1's adverse event. Personnel #2 stated that there was none.

Based on record review and interview, the facility's registered nurse (RN) did not administer Diprivan as ordered by the physician in accordance to acceptable standards of practice for 1 of 1 patient (Patient #1) who received Diprivan.

Note: Diprivan is an intravenous sedative-hypnotic agent which can be use as sedation in adults during intensive care. Definition derived from the medication insert (Fresenius Propoven 1%).

Findings:
On 07/23/10 at 1020, Physician #2 ordered "Diprivan drip - begin 10 ug/ min - call for agitation." The RN (registered nurse) administered Diprivan drip 10 milligram/ minute for approximately 1-1/2 hours starting at 1130 AM. The patient received the total of 100,000 mcg before Diprivan was discovered the dosage range was inaccurate.

In an interview the morning of 08/30/10, the afternoon of 09/01/10, and the morning of 09/02/10 via phone, the Registered Nurse (RN) (Personnel #4) was asked why he did not verify the physician's Diprivan order. The RN replied that he "was sure that the order read mg (milligrams)." The RN stated he was not aware of the dose range of Diprivan. Personnel #4 was asked how long he infused Diprivan (10 mg/ ml). He replied "approximately 1-1/2 hours." Personnel #4 was asked if this was the first time he administered Diprivan in the facility. He replied "yes."

Policy: "Medication Management" dated 01/01/09 required "1. Prior to administration of an intravenous medication, the Registered Nurse is to have knowledge of the drug's dose range, use, action, adverse reactions and nursing complications."