Western State Hospital was issued a notice of Immediate Jeopardy on Thursday, Feb. 25, 2016, due to a medication error.
The IJ said, “The facility failed to protect patients from immediate harm due to the following: “The hospital failed to ensure that staff members followed hospital policy, procedures and standards of practice for patient identification prior to medication administration and procedures. This posed a serious risk of harm to patients.”
Western State Hospital administers 9,500 doses of medication each day.
On Wednesday, Feb. 25, a patient was given the wrong medications. Key contributors to this mistake were the failure to use two patient identifier and pre-setting the medication.
Staff reported the error as soon it was discovered.
Nurses involved in administering medications have met with hospital leadership to identify the cause of the error and take steps to prevent it from happening again.
“We thank staff for reporting this incident to hospital leaders and the CMS survey teams,” said Carla Reyes, assistant secretary, DSHS Behavioral Health Administration. “We continue to make improvements in all areas of patient care and safety. Hospital staff are evaluating root causes for this situation and working together to identify solutions that will result in safer patients and improved quality of care.”
The hospital sent out the following reminder on safety measures Thursday:
- Before administering medication, Licensed Nurses must ensure the “five rights”
- Right patient: have you used TWO identifiers to ensure you are administering medications to the right patient?
- Right medication: have you checked to make sure this is the correct medication?
- Right dose: have you checked the prescribed dose against the dose on the medication?
- Right route: are you administering medication as it is prescribed?
- Right time: have you checked to make sure you are administering this medication at the right time?
- Acceptable forms of identification are:
- Photo identification
- Patient’s first and last name: ask patient to identify him or herself
- Date of Birth: ask patient date of birth
- Another staff member who can confirm the patient’s identity
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If possible, please ensure that you have a second person helping to manage the medication line.
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Effective immediately: setting up (pre-setting) medication in advance of medication administration is unacceptable.
Patients that require “as needed” medications that have been prescribed by a physician, must be evaluated by a registered nurse before those medications are administered.