Medication Administration Error Due to Order Misinterpretation
Penalty
Summary
Nursing staff failed to ensure the correct administration of Methadone to a resident with complex medical conditions, including acute respiratory failure, subdural and intracerebral hemorrhage, pneumonitis, and tracheostomy status. The resident was cognitively intact, as indicated by a BIMS score of 15. Multiple Methadone orders were entered and discontinued over several days, with the final order specifying Methadone liquid 60 mg/7.5 ml by mouth once daily. On the day of the incident, a nurse administered four bottles (30 ml) of Methadone instead of the prescribed one bottle (7.5 ml), due to a misunderstanding of the order and incorrect transcription in the medication administration record (MAR). The error was not discovered until the following day during a narcotic count, which revealed a discrepancy in the Methadone supply. The nurse involved confirmed preparing the incorrect dose, and the error was only prevented from escalating because the resident refused to take the additional medication, recognizing the correct dose. The facility's investigation found that the order was not entered correctly in the computer system, and the nurse misinterpreted the intended dose due to the way the medication was supplied and documented. The facility's medication reconciliation policy required verification of medication orders, but this process was not effectively followed, leading to the medication error.