{"Short_Answer__76":"201905859","Date__77":"09\/16\/2019","Multiple_Choice__78":"Marilee Bengtson","Multiple_Choice__79":"Sara Beauchene","Short_Answer__80":"Meridian Services, Inc - Kentucky","Short_Answer__81":"Ginny Benson","Multiple_Choice__84":"Medication Error","Multiple_Choice__85":"Hennepin County","Date__86":"08\/09\/2019","Free_Text__87":"Vincent was released from the hospital on 8\/9\/2019 at approximately 10:30am to Meridian Services-Kentucky site.\r\nThis is a short term transition\/crisis home home until permanent placement can be found. On Vincent's discharge orders he was\r\nprescribed Depakote 500mg each morning and 2000mg each evening for mood irritability. This order was not put on Vincent's medication\r\nadministration record at the Meridian site. Due to not being on the MAR, Vincent was not administered this medication. The error was\r\ndiscovered today at approximately 3:50pm. After consulting with our LPN, the medication will be started tonight as ordered. Vincent's last\r\ndose of administration would have been on Friday, August 9th 8:00am at the hospital before discharge.\r\n\r\nThe MAR was created by Alan Sloan, Program Manager at Kentucky. He also did the initial set-up in the medi-set. Stephanie Hughes did\r\nthe double check on the medi-set prior to being made available to staff for administration.","Multiple_Choice__96":"1","Short_Answer__91":"Individual's Medication Administration Record (MAR) listed a daily medication as a PRN (as needed) medication.","True_or_False__94":"Yes","Free_Text__98":"Incident report description\r\nIndividual was discharged directly from the hospital to Meridian Kentucky, a Transition Home for adults.  Individual was prescribed Depakote 500 mg in the morning and 2000 mg in the evening every day for mood irritability per his discharge medication order.  Depakote was not put on the Medication Administration Record (MAR) at Meridian Kentucky as a daily medication, but as a PRN.  Due to not being on the MAR as a daily medication, the individual was not administered his medication for 8 administrations from 8\/9 to 8\/13.  The error was discovered mid-afternoon on 8\/13 and the Meridian LPN called and who recommended medication be started again at individual\u2019s night administration. \r\n\r\nDebriefing Information for Learning Point \r\nDebriefing date:\tNovember 18, 2019\r\nPerson debriefed:\tProgram Administrator\r\nMeridian staff, including the Program Manager of Kentucky went to the hospital to pick up individual to transport to Meridian Kentucky.  The Program Manager was given the individual\u2019s Medication Orders signed by a physician, a Discharge Summary and the individual\u2019s medication in prescription bottles.   At Meridian Kentucky, the Program Manager then completed the Medication Administration Record from the Discharge Summary which listed all the individual\u2019s prescribed medications.  The MAR\u2019s is used for staff to follow when administering the individual\u2019s medication.  Then a lead staff reviewed\/checked the MARS completed by the Program Manager for accuracy.  The lead staff signed off on the correctness of MARS.  \r\n\r\nThe Program Manager who completed the MARS no longer works for Meridian, not due to this incident but leaving state and was not available to be debriefed.  The Program Administrator (PA) of Meridian Kentucky was debriefed.  PA explained there are several checks and double checks documented in the process of completing a MARS.  The first was that when an individual is admitted directly from being discharged at hospital, that the actual signed Medication Order and the prescription bottles are to be reviewed to assure they match at the hospital.  Then the Program Manager should review the Medication Orders, and prescription bottles at the group home to again insure the match and then complete the MARS.  The PA stated that this was the first time the Program Manager had completed the MARS without supervision.  Then the process is the double checker, Lead Staff in this case, who was recently promoted and was her first time being a double checker, was to compare the signed order Medication Order, with the completed MARS, then compare the MARS to the created \u201cmedi-set\u201d of prescribed medications, then the completed medi-set back to the prescribed bottles. \r\n\r\nThe PA explained that the Program Manager was a newer employee to Meridian Services, had worked at this job for about 8 months, and again, it was the first time completing an intake and MARS independently.  The PA also stated the Program Manager developed the MARS with medication information from the Discharge Summary which also listed the prescribed medications.  The individual had an over the counter PRN listed on the Discharge Summary, and right below this PRN, Depakote was listed so it appeared it was also a PRN.  As stated previously, this was also the first time the Lead Staff, recently promoted, was responsible for double checking a MARS.  The Lead Staff noted the error around 4 days later.","Free_Text__100":"The Program Manager (PM) listing the daily medication as a PRN medication in the Medication Administration Record (MAR) was influenced by it being the PM's first time creating a MAR for a new admission of a person that was coming from a hospital discharge. The PM was working in an unfamiliar environment coordinating a discharge from the hospital and had never completed the forms related to both a hospital discharge and new admission to the provider. Further complicating this process was that PM felt pressure from the hospital to complete the discharge quickly. In turn, the PM felt rushed to complete the discharge process which includes creating a MARS due to hospital beds are in high demand due to a very low availability of psychiatric beds. This is influenced by the state regulating the number of hospital beds that need to be available as psychiatric beds.   \r\n\r\nOn the hospital discharge summary report the medications were in a list. The daily medication was listed right below the PRN category which influenced the PM's decision to list it as a PRN. The confusing layout of the discharge summary was influenced by the hospital's lack of understanding of licensed crisis homes.\r\n\r\nAdditionally, the PM listing the daily medication as a PRN medication was influenced by it being their first time creating a MAR without the house supervisor. The PM didn't typically work with PRNs and when they did, the house supervisor was leading the process in creating the MAR. \r\n\r\nAfter the MAR was completed, the home\u2019s House Supervisor double checked the MAR for accuracy. Further contributing to the daily medication being incorrectly listed in the MAR is that the House Supervisor that completed the double check didn't catch the error on the MAR. The House Supervisor not identifying the error was influenced by her being new to the position and it was the first time they completed a double check of a MAR after a hospital discharge.   The double checker  may have been hesitant to correct her direct supervisor.\r\n\r\nAn additional factor influencing the PM listing the daily med as a PRN was that the MAR is created by the provider. Staff felt like the provider staff are not as knowledgeable about medications as a hospital or pharmacy would be. It was the provider's responsibility to create the MAR when the person was discharged from the hospital. The provider had a practice of signing and preparing medication orders 24-48 hours before admission to the provider\u2019s residence. Confirming medication regimen prior to admission was a practice developed to decrease medication errors and ensure continuity between settings. However, sometimes there are medication changes at the hospital during that 24-48 hour window and that information may not be shared or updated within the MAR. While this practice of preparing the medication order in advance wasn\u2019t required, it was influenced by licensing and liability laws for providers and the medication administration policies the provider created.  The provider\u2019s medication administration policies were influenced by the county assigning the responsibility to providers and 245D licensing requirements.","Multiple_Choice__101":"0","Multiple_Choice__103":"0","Multiple_Choice__105":"0","Multiple_Choice__107":"0","Multiple_Choice__109":"3","Free_Text__110":"On the hospital discharge summary report the medications were in a list. The daily medication was listed right below the PRN category which influenced the PM's decision to list it as a PRN. The confusing layout of the discharge summary was influenced by the hospital's lack of understanding of licensed crisis homes.\r\n\r\nThe provider had a practice of signing and preparing medication orders 24-48 hours before admission to the provider\u2019s residence. Confirming medication regimen prior to admission was a practice developed to decrease medication errors and ensure continuity between settings. However, sometimes there are medication changes at the hospital during that 24-48 hour window and that information may not be shared or updated within the MAR. While this practice of preparing the medication order in advance wasn\u2019t required, it was influenced by licensing and liability laws for providers and the medication administration policies the provider created.  The provider\u2019s medication administration policies were influenced by the county assigning the responsibility to providers and 245D licensing requirements.","Multiple_Choice__111":"3","Free_Text__112":"The Program Manager (PM) listing the daily medication as a PRN medication in the Medication Administration Record (MAR) was influenced by it being the PM's first time creating a MAR for a new admission of a person that was coming from a hospital discharge.  The PM was working in an unfamiliar environment coordinating a discharge from the hospital and had never completed the forms related to both a hospital discharge and new admission to the provider.\r\n\r\nAdditionally, the PM listing the daily medication as a PRN medication was influenced by it being their first time creating a MAR without the house supervisor. The PM didn't typically work with PRNs and when they did, the house supervisor was leading the process in creating the MAR. \r\n\r\nFurther contributing to the daily medication being incorrectly listed in the MAR is that the House Supervisor that completed the double check didn't catch the error on the MAR. The House Supervisor not identifying the error was influenced by her being new to their position and it was the first time they completed a double check of a MAR after a hospital discharge.","Multiple_Choice__113":"3","Free_Text__114":"On the hospital discharge summary report the medications were in a list. The daily medication was listed right below the PRN category which influenced the PM's decision to list it as a PRN. The confusing layout of the discharge summary was influenced by the hospital's lack of understanding of licensed crisis homes.","Multiple_Choice__115":"2","Free_Text__116":"The provider had a practice of signing and preparing medication orders 24-48 hours before admission to the provider\u2019s residence. Confirming medication regimen prior to admission was a practice developed to decrease medication errors and ensure continuity between settings. However, sometimes there are medication changes at the hospital during that 24-48 hour window and that information may not be shared or updated within the MAR. While this practice of preparing the medication order in advance wasn\u2019t required, it was influenced by licensing and liability laws for providers and the medication administration policies the provider created.  The provider\u2019s medication administration policies were influenced by the county assigning the responsibility to providers and 245D licensing requirements.","Multiple_Choice__117":"2","Free_Text__118":"Further complicating this process was that PM felt pressure from the hospital to complete the discharge quickly. In turn, the PM felt rushed to complete the discharge process which includes creating a MARS due to hospital beds are in high demand due to a very low availability of psychiatric beds","Multiple_Choice__119":"1","Yes_or_No__432":"Yes"}