Deficiencies in Pharmacy and Nursing Processes at the Southeast Louisiana Veterans Health Care System in New Orleans

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns that the failure to follow pharmacy and nursing policies and procedures may have contributed to a patient’s death at the Southeast Louisiana Veterans Health Care System in New Orleans (facility). Following a code blue on the medical-surgical unit, a patient with multiple medical conditions was transferred to the intensive care unit (ICU). The patient’s provider ordered intravenous (IV) fentanyl (a controlled substance) and IV norepinephrine. Due to the patient transferring to the ICU, new medication orders entered previously were discontinued. As a result, an ICU nurse was unable to scan the IV fentanyl label. Another ICU nurse called the pharmacy for a new IV fentanyl label. A pharmacy staff member failed to follow the intent of the facility policy and sent an unattached IV norepinephrine label to the ICU. Subsequently, another ICU nurse incorrectly affixed the IV norepinephrine label to the IV fentanyl bag. The ICU nurse failed to follow facility policy by not verifying the patient and medication information prior to affixing the incorrect label. The patient received the IV fentanyl, mislabeled as IV norepinephrine, at rates not prescribed. ICU nursing staff also failed to follow the infusion rate orders and did not assess the effectiveness of the medication or complete documentation to ensure an accurate record of medications administered. Additional concerns identified during the OIG inspection included an unsecured IV controlled substance and the facility did not conduct a thorough review of the medication error. The OIG made eight recommendations related to unaffixed medication labels; medication administration, medication orders, and compliance with Veterans Health Administration and facility policies regarding high-alert and high-risk medications; security of controlled substances; submitting Joint Patient Safety Reports; peer review; and institutional disclosure.