Drug error led to immediate jeopardy warning at Pennsylvania hospital

In August, a nurse at Main Line Health's Lankenau Medical Center in Wynnewood, Pa., mistakenly gave a patient double the prescribed dose of a powerful painkiller. The incident led to state regulators issuing an immediate jeopardy warning, according to an inspection report obtained by The Philadelphia Inquirer.

According to the inspection report, a nurse at the hospital on Aug. 11 gave a patient 3 milligrams of the opioid hydromorphone, double what was prescribed. The patient was revived with naloxone after being found unresponsive and transferred to the ICU for treatment. The nurse admitted to giving the wrong dose to the patient and was removed from the schedule, though a health system spokesperson did not confirm whether the individual was still employed when asked by the Inquirer

Inspectors found the nurse did not properly follow the hospital's protocol for administering medications and did not properly document vials of hydromorphone removed from the medicine cabinet, which led to the dosage error. An immediate jeopardy warning was issued on Aug. 23 and lifted a day later, after all nurses at the hospital were retrained on "medication administration, wasting of controlled substances, controlled substance inventory discrepancy procedures, and controlled substances monitoring." The hospital also agreed to conduct 30 observation audits per week for at least 30 days. As of Sept. 28, the hospital had met its auditing goals. 

"Providing safe, high-quality, and equitable care to our community is our top priority. We take the situation very seriously and have implemented immediate and ongoing steps to correct any deficiencies identified by the state," Larry Hanover, a spokesperson for Main Line Health, said in a statement to the news outlet. 

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