Medication Transcription Error Leads to Extra Doses Administered
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to accurately transcribe a medication order for a newly admitted resident who was transferred from a hospital for rehabilitation. The resident, who was alert but confused and mostly nonverbal, was prescribed Metoprolol Succinate ER 25 mg to be administered once daily according to hospital discharge instructions. However, the medication was incorrectly entered into the electronic medical record as 25 mg twice daily, resulting in the resident receiving three extra doses of the medication. The error was identified through a review of the resident's progress notes and medication administration record, which showed a discrepancy between the hospital order and the facility's transcription. Further review revealed that the nurse responsible for the transcription error had a documented history of similar medication errors, including previous incidents involving incorrect medication entry, failure to report errors promptly, and administration of medications to the wrong resident. The facility's policy required a second nurse to double-check medication orders against the original list, but this process was not followed. The nurse had not completed required education on medication error prevention prior to working additional shifts after the incident, and documentation of previous corrective actions was incomplete.