Improper Medication Administration Timing Results in Elevated Error Rate
Penalty
Summary
The facility failed to follow proper medication administration protocols for a resident prescribed Levothyroxine, Omeprazole, and Acetaminophen. According to the Medication Administration Record (MAR), these medications were scheduled and administered together during the early morning medication pass. The MAR and electronic medical record indicated that Levothyroxine and Omeprazole were both given at 5:02 am, and Acetaminophen was given at 5:06 am, all within the same medication pass window. The Director of Nursing confirmed that Levothyroxine should not be administered with other medications, as it is required to be given on an empty stomach and separated from other medications to ensure proper absorption. The facility's own pharmacy guidance and medication pamphlet for Levothyroxine specified that it should be administered once daily on an empty stomach, at least half an hour before breakfast and at least four hours apart from other medications that could interfere with its absorption. Despite this, the medications were administered together, resulting in three medication errors out of 30 opportunities, which led to a medication error rate of 10 percent. The error was attributed to a transcription issue that scheduled the medications at the same time.