Significant Medication Error Due to Incorrect Drug Administration
Penalty
Summary
A deficiency was identified when a resident with a history of left femur fracture, arthritis, hyperlipidemia, cerebrovascular disease, and dysphagia was administered the incorrect medication. The resident had a physician's order for aspirin-dipyridamole (Aggrenox) 25-100 mg to be given twice daily, but there was no order for aspirin 81 mg daily. During a medication pass observation, a registered nurse prepared and administered aspirin 81 mg instead of the prescribed aspirin-dipyridamole. The nurse confirmed during an interview that the incorrect medication was given. Review of the facility's policy on administering oral medications indicated that staff are required to verify the physician's order, check the medication label, and confirm the medication name and dose with the Medication Administration Record (MAR). The failure to follow these procedures resulted in a significant medication error for the resident.