Medication Error Due to Inadequate Physician Review
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including medications, which led to a medication error. A resident with bilateral knee osteoarthritis and muscle weakness was prescribed Tylenol 1000 mg every 8 hours by an Orthopaedic Surgery Specialist. However, the resident was already receiving Tylenol 8-hour oral tablet extended release three times a day for pain, with a maximum dosage of 3 grams per 24 hours. This oversight resulted in the resident receiving over 15,000 mg of Tylenol over three days, significantly exceeding the recommended dosage. The error occurred because the Certified Nurse Practitioner, working in coordination with the resident's attending physician, signed off on the new order without realizing the existing Tylenol prescription. Interviews with staff revealed that the resident should not have received more than 3,000 mg per day due to potential liver damage. Despite the excessive dosage, subsequent laboratory testing and monitoring showed no concerns with the resident's condition.
Plan Of Correction
1. The facility cannot retroactively correct the failure to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing services to assure resident safety or maintain the highest practicable physical well-being of each resident. All Tylenol orders will be updated to ensure max dose/24 hrs alert is noted on the order to prevent from over medicating. All orders must be handwritten and signed by the provider on facility order sheets; there will be no more taking After Visit Summaries and circling orders, they must be written out on the correct order sheet or verbal can be taken with readback to prevent confusion with new orders. 2. DON/designee will perform a house sweep on all residents who are on Tylenol to ensure dosing is correct, max dose alert on order, and there are no duplicate orders. 3. DON/designee will re-educate nursing staff on 5 rights of medication administration, and will have updated competencies over the next 90 days. Nursing staff will also be educated on Tylenol dosing, including max dose in 24 hours. Nursing staff and providers (MD's, CRNP's, PA-C's) will be educated on our Physician Order Entry-Clinical System Process which reviews the following topics: guidance/expectations of order entry, date required prior to order entry, orders and interim order entry, order alerts, custom medications, dispense as written, practitioner read back, drug recalls, duplicate orders, utilizing the lab logs, and additional topics which include respiratory, dietary, etc. 4. DON/designee will perform weekly audits x4 on residents batch orders (standard orders) to ensure they are appropriately placed, no duplicates. Batch orders include medications like Tylenol, MOM, stool softeners. This will hopefully minimize duplicate orders for commonly ordered medications as mentioned above. Audit will contain 8 residents per week. 5. Results will be reported to QAPI for review and further recommendations if needed.