Medication Error Rate Exceeds 5% Due to Failure to Follow Physician Orders and Dosage Verification
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less during a medication pass, resulting in a cumulative error rate of 10% based on three errors out of 30 opportunities. During medication administration, a nurse prepared to give two medications, Hydrochlorothiazide and Verapamil, to a resident with a history of heart disease and hypertension. Although the nurse checked the resident's blood pressure, she did not check the heart rate as required by the physician's order, which specified to hold the medications if the systolic blood pressure was below 110 or the heart rate was below 60. The omission was identified by a surveyor before the medications were administered, and the nurse acknowledged forgetting to check the heart rate, confirming that both blood pressure and heart rate should be assessed prior to administration due to the medications' effects on these parameters. In another instance, a nurse prepared to administer Cyanocobalamin (Vitamin B12) to a resident with hypertension and hyperlipidemia. The physician's order specified a daily dose of 500 mcg, but the nurse was observed preparing a 1000 mcg tablet instead. The error was identified by the surveyor before administration, and the nurse confirmed that the incorrect dose was about to be given, stating that the physician's order was for 500 mcg and that giving 1000 mcg would be an error. Review of the facility's policies and procedures indicated that medications are to be administered in accordance with physician orders, and that medication labels and dosages must be verified against the medication administration record. The policies also require that vital signs be checked prior to administration when prescribed. The Director of Nursing confirmed that these procedures were in place and that failure to follow them could result in medication errors.