Failure to Discontinue Duplicate Buspirone Orders Resulting in Excessive Dosing
Penalty
Summary
A deficiency occurred when a resident with quadriplegia and generalized anxiety disorder received duplicate orders for Buspirone 5 mg, resulting in the medication being administered both two times a day and three times a day over a period of time. Record reviews showed that both orders were active and being administered concurrently, with documentation on the Medication Administration Records (MAR) confirming that the resident received both regimens. The issue was identified when a nurse placed a call to the physician to clarify the Buspirone orders, and the duplicate order was subsequently discontinued. Interviews with facility staff, including an LPN, medication aide, ADON, DON, and the Administrator, revealed that the previous Buspirone order should have been discontinued when the new order was entered, but this did not occur. Staff acknowledged the presence of duplicate orders and the risk of medication errors, with the facility's policy indicating that new physician orders are to be reviewed for accuracy during daily clinical meetings. At the time of observation, the resident was alert and showed no signs of distress, and did not report any concerns regarding his medications.