Significant Medication Errors Due to Order Transcription and Administration Failures
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication order transcription and administration. One resident, who was cognitively intact and required assistance with mobility and daily activities, was mistakenly prescribed and administered Lexapro (an antidepressant) and Seroquel (an antipsychotic) for a period of 12 days. These medications were not part of the resident's original regimen and were intended for another resident with a similar last name. The error was discovered during a discharge medication review with the resident's family representative, who alerted the nurse that the resident had never been on those medications. The nurse confirmed the error after reviewing the medication list and contacting the prescriber, who acknowledged that the orders were made in error. There was no documentation in the progress notes regarding the verbal orders received, nor was there a physician's order noted for the verbal order given. Another resident, who had moderate cognitive impairment and required significant assistance with daily activities, did not receive recommended changes to their psychotropic medication regimen in a timely manner. Following a psychiatry consult, recommendations were made to adjust the resident's Seroquel and Lexapro dosages due to improved condition and lack of behavioral issues. However, the recommended changes were not initiated for several days, and the medication administration record did not reflect the adjustments as ordered. The resident continued to receive the previous dosages beyond the recommended change date, and the consult notes did not accurately reflect the resident's current medication regimen. The facility's policy required that all medication orders, including changes and discontinuations, be documented in the resident's medical record and that verbal orders be documented immediately and signed by the physician within 24 hours. In both cases, there was a lack of proper documentation and verification of medication orders, leading to administration errors. The errors were attributed to confusion between residents with similar last names and a lack of regular familiarity with the residents by the nurse transcribing the orders. The events were confirmed through interviews with nursing staff and the prescriber, as well as review of medical records and facility documentation.