Reference no: EM133282751

What is the process an HIM professional would need to take to report the violations in the scenario to the appropriate internal party?

SCENARIO:

Mary K. Emerson is a patient at Felder Community Hospital. She was admitted six days ago due to a diabetic episode and an upper respiratory infection that left her unresponsive at work. She was admitted to the ICU, and medical staff attempted to stabilize her condition. Unfortunately, there were some problems with her care due to the wrong information being entered into the patient's medication record in her chart.

When the nursing staff was trying to update her medications from a previous admission, they chose Mary J. Emerson, who was also a patient admitted around the same time to another unit, instead of the current patient, Mary K. Emerson. To treat Mary K. Emerson's respiratory infection, penicillin was ordered based on Mary J. Emerson's chart that showed no known allergies. Mary K. was given the penicillin but was found to have an extreme allergy, which sent her into acute respiratory distress. The penicillin was administered and documented on Mary J. Emerson's chart before the clinical staff noticed the error.

As Mary K. remained in the ICU and drifted in and out of consciousness, clinical staff tried to make sure she remained on schedule with her medications. On two noted occasions, the scheduled dose of 30 units of insulin that was to be administered subcutaneously with meals was delayed during the shift. On a separate occasion, the nurse tech drew up 40 units to be administered intramuscularly instead of the prescribed subcutaneous route. This resulted in the incorrect angle and depth of the injection used for the prescribed insulin.

On the fifth day of her admission, Mary K. was exhausted from the testing and medication changes. When the nurse came in to administer her scheduled dose of insulin, she stated "Please, no more meds".