Medication Labeling Error Leads to Resident Receiving Wrong Drug
Penalty
Summary
The facility failed to ensure accurate labeling of medication for a resident, identified as Resident B3, which led to a medication error. The resident, who was cognitively intact and had a history of irritable bowel syndrome and chronic pain syndrome, was supposed to receive Dicyclomine HCl 20 mg for her condition. However, due to a pharmacy packaging error, the medication labeled as Dicyclomine was actually Doxycycline, an antibiotic. This error was discovered after the resident experienced nausea and vomiting following the administration of the incorrect medication. The incident occurred when the resident refused her nighttime dose, citing adverse effects from the previous dose. Upon investigation, it was confirmed that the medication package was mislabeled, and the resident had been given Doxycycline instead of Dicyclomine. The nurse administering the medication noted the discrepancy in capsule size but proceeded with administration. The facility's policy required verification of medication labels three times before administration, which was not effectively followed in this case, leading to the error.
Plan Of Correction
- B3-label corrected for appropriate medication with appropriate label. - House audit completed on current residents related to labeling of medications. The NHA and DON addressed the current pharmacy in relationship to the mislabeling of the medication. Nursing staff have been re-educated on protocol for receiving and checking in medication once received from the pharmacy. - Re-education on policy entitled, "Administration of Medications", reviewed with all licensed staff. - The DON or designee will conduct weekly audits x 4, then monthly x 2 on medication administration and the receiving medications from pharmacy. - Audits will be presented at monthly QAPI committee for ongoing oversight.