Friday, June 8, 2018
Abington Hospital Cited in Medication Error
By Walter F. Roche Jr.
Reaching back nearly two years, Pennsylvania health officials have cited Abington Hospital for a "mishap" in which a patient was given a dose of a medication four times the strength prescribed by her doctor.
In a six-page report recently made public, the health department surveyors found that a resident physician and his supervisor failed to properly perform a medication reconciliation process when the woman appeared at the hospital's emergency room on July 10, 2016.
Instead, the report states, they relied on the incorrect information provided by the patient's husband. Apparently overlooked was a fax from the woman's primary care physician, sent about 10 minutes before the wrong dosage was administered, listing the correct dosage of the cardiac medication, 5 milligrams three times per day.
A few hours after the patient was administered 20 milligrams of Midodrine on July 11, her blood pressure shot to 207/100 and she reported dizziness and other symptoms requiring rapid response team intervention.
In addition to failing to note the fax from the PCP, the surveyors cited the staffers for failing to ask the patient herself about the correct dosage.
Hospital records reviewed by the state showed the patient's own hospital record stated,"of note a mishap was made on the patient's medication reconciliation during admission."
Abington, a 665-bed facility, is part of Abington-Jefferson Health.
The report states that there was no record that the patient herself "was given the opportunity to confirm what the spouse may have discussed with the medical resident/attending physician in regards to their Midodrine dosage."
Stating that "there was no documented evidence that the patient was determined to be disoriented, incompetent and/or unable to answer questions," the report states that there was "no documented evidence that the admitting medical resident and/or their supervising attending physician made a good faith effort to involve the patient in the medication reconciliation process."
The report cites a notation in the patient's record stating "Minimizing midodrine dose may help prevent future hemorrhages."
A subsequent hospital record from the Rapid Response Team questioned the 20 milligram dosage.
"Need to clarify the dose of Midordine as 20 mg three times a day, seems a very high dose which is usually not recommended,"the record states, adding that no further doses should be administered.
"Hold Midodrine for now," the note states.
Abington filed a plan of correction which included the implementation in the pharmacy system to alert pharmacists when dosage of Midordine exceeds the usual range."
Hospital officials did not respond to a series of questions about the incident.