HospitalInspections.org

Based on facility policy, medical record review, and interviews, facility staff members, who reviewed Patient Identifier (PI)# 1's medical record prior to the survey, failed to identify a medication error and failed to contact PI# 1 after discharge (01/13/2010) to determine if he (PI# 1) experienced a negative outcome related to this medical error.
This deficient practice effected PI# 1, one of ten sampled patients.
Findings Include:

1. Facility Policy:
The hospital policy entitled " Quality and Patient Safety Program Plan " includes:
"...PURPOSE...of this Quality and Patient Safety Plan ... is to provide a framework for an organization-wide Quality program and an approach to medical care error prevention ...
...OBJECTIVES...
...To foster an organizational culture that promotes identification, reporting analysis and prevention of actual and potential risks to patient safety ...
...To implement a formal, timely process of intensive analysis for sentinel events and near miss occurrences that focuses on process and systems and not individuals ...
...To communicate quality and patient safety information through the organization in a timely manner.
...RESPONSIBILITY
...Support an ongoing proactive patient safety program ... includes review of patient safety data, including root cause analyses, sentinel event alerts, failure mode effects analysis ...and other patient safety measures ...Unit specific managers are responsible for compliance with ...patient safety goals and all activities of improvement ...for their departments.
...Employees are responsible for participating in quality and patient safety activities as appropriate ...All staff are responsible to communicate risk issues in a timely manner..."


2. Medical Record Documentation:
Patient Identifier (PI)# 1 presented to the emergency department on 01/13/2010, with complaints of back pain. The " Emergency Nursing Record ...Back Pain / Injury " includes:
"...Location of Pain...L-spine...sacral"
"...Allergies...Lortab - makes crazy..."

The "EMERGENCY PHYSICIAN RECORD...Low Back Pain / Injury" is dated 01/13/2010 and signed by the emergency physician. This record includes:
"...Allergies...Lortab...PROGRESS:...improved ...Counseled patient/rad [radiology] results/ need for follow-up...CLINICAL IMPRESSION: Fall ...Acute...Low Back Pain
DISPOSITION home...CONDITION Improved...Discharge Medications ...Lortab..."

The "Patient Discharge Instruction Summary," dated 1/13/2010 at 15:48, includes:
"...Drugs Prescribed...Lortab...prn [as needed] severe pain...Avoid taking with alcohol or with driving/working...Substitute OK..."
This form is signed by PI# 1 and the nurse who completed the emergency nursing assessment.

3. Interviews:
On 2/23/2010 at 2:20 PM, emergency department (ED) registered nurse that completed PI# 1 ' s emergency nursing assessment, and discharge instructions, was interviewed. When asked about the Lortab orders, this RN stated she did not realize PI# 1 ' s prescriptions included Lortab, a medication listed in PI# 1 allergies.

On 2/23/2010 at 3:00 PM, the emergency Nurse Manager stated he reviewed PI# 1 medical record prior to the survey but did not notice the physician ordered (and the discharge summary noted) PI# 1's home medications included Lortab; A medication PI# 1 listed as a drug he was allergic to.

On 2/23/2010 at 3:55 PM, emergency room physician (during an interview) did not recall PI# 1 but stated if he ordered Lortab, the drug was probably "switched out" and not given to PI# 1, and it was not known if the patient filled the Lortab prescription.

On 2/23/2010 at 4:45 PM, a Quality Management (QM) Nurse Manager, who reviewed PI# 1 emergency record prior to the survey, stated he/she (Nurse Manager) was not aware that the emergency room physician ordered a medication listed in PI# 1's allergies. This Nurse Manager acknowledged that hospital staff failed to identify this medication order as a medical error, failed to determine if PI# 1 filled the prescription for Lortab, or ascertain if this patient suffered an undesirable outcome post discharge, related to Lortab.

On 2/25/2010 (following the survey) the facility submitted corrective action plan that include:
a) Follow-up phone calls to PI# 1"s home relative to patient concerns and or condition post discharge
b) An " extensive " chart review of PI# 1's medical record from the 01/13/10
c) A list of opportunities for process improvement steps.
d) Review and amendment of the facility's grievance policy, submitted for committee approval on 2/25/2010.