DOH Shares Immediate Jeopardy Information

DOH shared information recently with LeadingAge New York regarding the dramatic increase of Immediate Jeopardy (IJ) citations for medication errors. A number of these situations involve significant breakdowns in the system designed to ensure that residents received the medication ordered by the physician. Among the problems identified were the lack of availability of the medication, failure of the pharmacy to provide timely delivery, a lack of communication between nursing staff and physician, and an absence of an investigation of medication errors to examine root cause issues. Medications that were not administered included critical medications such as Insulin, Coumadin, Augmentin, Sinemet, Aricept, and Dilantin. As of mid-August , there were nine IJ citations for medication errors as compared to four in 2012. LeadingAge New York staff have been working closely with members to identify potential areas of vulnerability in their medication systems.

Contact:  Elliott Frost, efrost@leadingageny.org, 518-867-8832