After a nurse at Tahlequah, Okla.-based W.W. Hastings Hospital improperly administered medication through a reused syringe, the hospital is improving infection control, nursing services and medication administration practices — an effort prompted by a CMS survey finding it was out of compliance, the Tahlequah Daily Press reports.
Six things to know:
1. The CMS survey was linked to an incident earlier this year when a nurse improperly administered medication through a reused syringe, potentially exposing 186 patients to HIV and hepatitis C. The son of Cherokee Nation's principal chief was later identified as the nurse in question.
2. CMS accepted the hospital's plan to correct areas where it was deemed out compliance, including nursing services, pharmaceutical services and infection control.
"The hospital nursing services failed to have a comprehensive nurse training program that addresses pharmacy compounding medication and nursing preceptor program," the survey said. "This failed practice [has] the potential to affect all inpatients and outpatients and [who] receive care on a daily basis." The hospital created a comprehensive nurse training program to address compounding sterile products as part of its action plan.
3. To address its compliance with pharmaceutical services, the plan updates the hospital's medication administration policy. The policy does not allow nursing students to administer medications; requires the pharmacy to review all medication orders before administration; and requires nurses who administer a narcotic dose to comply with Bar Coded Medication Administration.
4. The plan also says staff members involved in preparing and administering medications were told: "Vials and syringes are for single-dose and used on time; needles and syringes are single-use devices and not to be used on more than one patient or reused to draw up additional medication; and, not to administer medications from a single-dose vial or IV bag to multiple patients."
5. The hospital took several steps to address infection control deficiencies CMS found. Hastings put sanitizing wipes in the medication preparation area; directed staff that medications from the Omnicell are for immediate use; and instructed staff on surgical attire and infection control precautions.
It also put in devices for staff to hang IV bags; sharp containers in areas closest to medication administering; and hygiene units in the pre-operative and post-anesthesia care units.
6. "We truly value the feedback from CMS and are continuing our implementation of this approved action plan," said Charles Grim, DDS, executive director of Cherokee Nation Health Services. "The true value here is turning that feedback into positive change. We'll continue working with our partners to advance best practices and improve procedures at W.W. Hastings Hospital."
The completion date for implementing the plan is Aug. 31.