Significant Medication Error: Administration of Sulfa Antibiotic to Resident with Documented Sulfa Allergy
Penalty
Summary
A significant medication error occurred when a resident with a documented allergy to sulfa drugs, specifically Sulfasalazine, was administered Sulfamethoxazole-Trimethoprim (Bactrim), an antibiotic containing sulfa. The resident's care plan and Medication Administration Record (MAR) both clearly indicated the sulfa allergy, and the facility's policy required staff to check for allergies before administering medications. Despite these safeguards, the antibiotic was ordered and administered multiple times, even after the pharmacy flagged the allergy and communicated concerns to nursing staff. The resident, who had multiple diagnoses including MRSA UTI, kidney stones, and a history of antibiotic allergy, began receiving the sulfa-containing antibiotic as per physician and nurse practitioner orders. Nursing notes documented the resident's complaints of a sore throat, difficulty swallowing, and the development of a rash after administration of the medication. The allergy was noted in the records, and the pharmacy communicated the risk to the facility, but the medication continued to be given until it was eventually discontinued following further adverse reactions. Interviews with facility staff revealed a lack of appropriate response to the allergy warnings. The nurse practitioner admitted to carrying over the antibiotic order from a hospital consultation and did not consider the allergy significant, while the physician acknowledged that administering the medication was a mistake. The pharmacy confirmed that the allergy was flagged and communicated, but the medication was still dispensed and administered, indicating a breakdown in the facility's medication administration and allergy verification processes.