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Based on document review and interview Nursing Services failed to document event follow-up and re-education to staff involved in a medication error for 1 of 10 MRs (Medical Records) reviewed. (P4)

1. Facility policy titled Adverse Event Management and Error Reporting, no policy number, Publication Date: 09/26/2022, Page 4, Under VI. Procedures, d. The Apparent Analysis or Root Cause will entail: iii. The conduction of a meeting of the persons involved and any identified experts to review the findings and approve the identified root cause(s). iv. Determination of a risk reducation strategy and action plan that includes the measurement of the effectiveness of process and system improvements to reduce risk. Such action plan will include responsibility and a time frame for the identified actions. e. Any new or modified processes identified as actions by the team shall: ii. Meet the needs of the individuals served, staff and others. vi. Incorporate the results of performance improvement activities.

2. Incident Abstract Report Riskonnect form dated 11/7/24 at approximately 0400 hours indicated P4 had a Hydromorphone PCA (Patient Controlled Analgesia) that had been set up on day shift by N1 (RN [Registered Nurse] Labor & Delivery) and witnessed by N2 (RN Postpartum). The night shift nurse, N3 (RN Labor and Delivery), had not had a patient with a PCA before and was unaware that he/she needed to verify settings at shift change. At around 0115 hours, N3 had N4 (RN Postpartum) accompany her to P4's room because the PCA was alarming that the maximum dose had been reached and he/she was unsure how to clear the alarm. N4 showed N3 how to check shift totals and at that time they realized that the PCA showed only two dose attempts with no doses delivered, so it could not have been maxed out. When N3 and N4 verified the settings, they saw that the PCA had been programmed with a continuous dose of 1mg (milligram) per hour, but a continuous dose had not been ordered. The other program details were correct. The one-hour lockout dose was 1 mg, so that is why the PCA alarmed when P4 attempted to administer a dose. N4 noticed that the PCA key had also been left inserted into the PCA. N3 and N4 reprogrammed the PCA with the correct details and removed the key. It was also noted the PCA had not been charted in Cerner (computer charting system) in the Intake & Output Flowsheet. Incident report lacked documentation of follow up/education with N1 and N2 regarding medication error, key left in PCA and charting on the Cerner Intake and Output Flowsheet.

3. Email dated 12/19/24 at 1101 hours from A15 (Manager of Clinical Operations NICU [Neonatal Intensive Care Unit] and Pediatrics) indicated a debriefing took place on 11/7/24 at approximately 0930 hours regarding medication error involving P4. Debriefing lacked documentation of a sign in sheet including but not limited to staff involved in the medication error.

4. Email dated 12/19/24 at 1301 hours from A19 (Clinical Advisor) indicated on 11/7/24 N2 was very upset by medication error and a PCA pump was set up and reviewed with N2. Other nurses gathered around the PCA but A19 was unsure of the staff that reviewed the PCA pump during this time.

5. In interview on 12/19/24 at approximately 1400 hours with A17 (Manager of Clinical Operations Postpartum), he/she indicated A14 (Risk Manager) did a huddle with a debriefing regarding PCA medication error with N2 and other nurses on the Postpartum Unit on 11/7/24. A17 confirmed there was not a sign in sheet regarding what education was given and who attended.

6. In interview on 12/19/24 at approximately 1430 hours with A18 (Director of Perinatal and Pediatrics), he/she confirmed there was no follow-up and/or re-education documented with N1 regarding PCA medication error.

Based on document review and interview Nursing Services failed to administer ordered medication in accordance with physician orders, failed to maintain PCA (Patient-Controlled Analgesia) pump keys in a secure place, and failed to maintain documentation of PCA Intake and Output for 1 of 10 patient MRs (Medical Records) reviewed. (P4)

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner

Based on document review and interview Nursing Services failed to administer ordered medication in accordance to physician orders, failed to maintain PCA (Patient-Controlled Analgesia) pump keys in a secure place, and failed to maintain documentation of PCA Intake and Output for 1 of 10 patient MRs (Medical Records) reviewed. (P4)

Findings include:

1. Facility policy titled Patient Controlled Analgesia, no policy number, Publication Date: 10/24/2023, under I. Purpose, To provide for safe and effective pain management using a patient-controlled analgesia (PCA) infusion pump for delivery of intravenous (IV) analgesics. Page 2, Under V. Policy Statements, K. Nursing Considerations: 9. PCA keys are controlled substance keys and will be monitored and kept in the possession of the responsible nurse at all times. PCA keys must be kept in a secure place except when being used to establish or change PCA settings or change PCA medication syringe. Page 5, Under VI. Procedures, O. Documentation 3. At a minimum, total PCA dose received is charted with every shift.

2. Facility policy titled Medication Administration and Management, no policy number, Publication date: 09/17/2024, Under I. Purpose, To ensure that medications are administered in a safe and effective manner, and in a manner that complies with all hospital, Joint Commission, state and federal regulations.

3. Review of P4 MR indicated:
a. On 11/6/2024 at 0736 hours a PCA order was entered by provider with following settings: PCA Dose mg (milligrams) = 0.2, Lock-out interval min (minutes) = 10, Max limit in one hour (mg) = 0.5.
b. On 11/6/24 at 1349 hours N1 (RN [Registered Nurse]) and N2 (RN) set up initial Hydromorphone PCA (Patient-Controlled Analgesia Pumps) settings.
c. MR lacked documentation of PCA Intake and Output on Nursing Flowsheet on 11/6/24.
d. Provider order entered for PCA to discontinued on 11/7/2024 at 0944 hours.

4. Incident Abstract Report Riskonnect form dated 11/7/24 at approximately 0400 hours indicated P4 had a Hydromorphone PCA that had been set up on day shift by N1 (RN [Registered Nurse] Labor & Delivery) and witnessed by N2 (RN Postpartum). The night shift nurse, N3 (RN Labor and Delivery), had not had a patient with a PCA before and was unaware that he/she needed to verify settings at shift change. At around 0115 hours, N3 had N4 (RN Postpartum) accompany her to P4's room because the PCA was alarming that the maximum dose had been reached and he/she was unsure how to clear the alarm. N4 showed N3 how to check shift totals and at that time they realized that the PCA showed only two dose attempts with no doses delivered, so it could not have been maxed out. When N3 and N4 verified the settings, they saw that the PCA had been programmed with a continuous dose of 1mg (milligram) per hour, but a continuous dose had not been ordered. The other program details were correct. The one-hour lockout dose was 1 mg, so that is why the PCA alarmed when P4 attempted to administer a dose. N4 noticed that the PCA key had also been left inserted into the PCA. N3 and N4 reprogrammed the PCA with the correct details and removed the key. It was also noted the PCA had not been charted in Cerner (computer charting system) in the Intake & Output Flowsheet. Incident report lacked documentation of follow up/education with N1 and N2 regarding medication error, key left in PCA and charting on the Cerner Intake and Output Flowsheet.

5. In interview on 12/19/24 at approximately 1410 hours with A16 (Manager of Clinical Operations, Labor and Delivery), he/she indicated N1 (RN [Registered Nurse]) that was pulled to Postpartum floor approached A16 on 11/6/24 in tears regarding his/her assignment on Postpartum Unit and was overwhelmed, N1 had not had a PCA pump prior to this assignment and required assistance from N2 to set the pump up. A16 confirmed the PCA pump was set up incorrectly with continuous dose instead of intermittent dose as ordered per provider, PCA key was left in the pump and not secured, and MR lacked documentation of PCA Intake and Output on Nursing flowsheets.