Pharmacist Failed to Identify and Report Repeated Medication Administration Errors
Penalty
Summary
A licensed pharmacist failed to identify and address repeated medication administration errors during monthly drug regimen reviews for a resident prescribed Midodrine for hypotension. The resident had specific parameters for administration, requiring the medication to be held if systolic blood pressure exceeded 120 or diastolic exceeded 80. Despite these parameters, the medication was administered outside of the prescribed limits 38 times in January, 44 times in February, and 35 times in March. The pharmacist's monthly reviews did not document these errors, and the majority of the errors went unreported to facility leadership. The pharmacist only partially acknowledged some errors in a February recommendation to nursing staff, listing a small sample of dates but not the full extent of the errors. No recommendations or notifications were made regarding the errors in January or March. Interviews with the pharmacist revealed she did not consider the errors clinically significant and believed that education provided to nursing staff would resolve the issue, though no such education had actually occurred. The pharmacist's monthly summary reports for all three months stated that no medication errors were noted. Facility leadership, including the DON, Unit Manager, Staff Development Nurse, and Administrator, were unaware of the medication errors until informed during the survey process. None of the nursing leadership had received reports or recommendations regarding the errors, nor had any education been provided to staff about medication parameters. The Medical Director confirmed that the pharmacist should have reported the errors as soon as they were discovered. The resident involved did not experience any significant outcome as a result of the errors.