Failure to Prevent Significant Medication Error Due to Unavailable Scheduled Pain Medication
Penalty
Summary
A significant medication error occurred when a resident with chronic pancreatitis, severe chronic kidney disease, and chronic pain did not receive seven scheduled doses of a long-acting pain medication (MS Contin ER 30 mg) as ordered by the physician. The medication was prescribed to be administered three times daily for pain management. The missed doses were due to the medication not being available at the facility on multiple occasions across March and April, as documented in the Medication Administration Record and nursing notes. Nursing staff and medication aides reported that the medication was not available to administer at the scheduled times, and in several instances, the pharmacy had not yet delivered the medication. Staff interviews revealed that the process for reordering medications was not consistently followed, with some staff not contacting the pharmacy or physician promptly when the medication supply was low or depleted. Instead, staff often relied on administering the resident's as-needed (PRN) pain medication in place of the scheduled long-acting medication, which was not equivalent in duration or frequency. The resident was aware of the missed doses and expressed confusion and concern about the facility's inability to maintain an adequate supply of his prescribed pain medication, especially given his ongoing need for pain control. The pharmacy consultant and medical director both confirmed that medications should be reordered before the last dose is given, and the medical director considered the missed doses a significant medication error. The DON and administrator were not aware of the missed doses until after the fact and acknowledged that medications should be available as ordered.