Medication Error Rate Exceeds Acceptable Threshold Due to Late and Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with six medication errors identified out of 34 opportunities, resulting in a 17.65% error rate. The errors affected two residents observed during medication administration. For one resident, a Licensed Vocational Nurse (LVN) administered only part of the scheduled 9:00 AM medications during the initial pass and returned later to give the remaining five medications, including magnesium oxide, aspirin, vitamin C, multivitamins, and gabapentin, after the acceptable administration window had passed. The LVN acknowledged that these medications were late and that this was due to splitting the medication pass, which was not her usual practice. Another error involved a different LVN administering the incorrect formulation of a cough medication to a resident with chronic obstructive pulmonary disease (COPD). The resident was prescribed guaifenesin 100 mg/5 ml oral liquid, but instead received Geri-Tussin DM, which contains a higher dose of guaifenesin and an additional active ingredient, dextromethorphan. The LVN admitted to not verifying the medication formulation against the physician's order and stated that she should have clarified the order with the physician before administration. The facility's policy on medication administration requires that medications be given as ordered by the physician and within 60 minutes of the scheduled time, unless otherwise specified. Both LVNs involved in the incidents acknowledged their errors and the importance of adhering to physician orders and facility policy to ensure safe medication administration.