Significant Medication Errors Due to Incorrect Drug and Dose Administration
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. In the first instance, a resident with a history of surgical aftercare and chronic lymphocytic leukemia was ordered to receive morphine sulfate extended release (ER) 15 mg every 12 hours for pain management. Instead, the resident was administered morphine sulfate immediate release (IR) 15 mg, which did not match the physician's order. The error was identified when the nurse reviewed the medication bubble pack and the order, noting the discrepancy. The resident reported inadequate pain relief and required additional doses of Norco for breakthrough pain, as documented in the electronic medication administration record (eMAR) and confirmed by the resident and nursing staff interviews. In the second instance, another resident with hypertension and heart failure was ordered benazepril 20 mg once daily. However, the resident was administered benazepril 40 mg, which was dispensed by the pharmacy in error. The nurse failed to identify the incorrect dose during medication administration, despite facility policy requiring verification of the correct drug and dose against the order and eMAR. The director of nursing confirmed that the pharmacy sent the wrong medication and acknowledged the risk associated with the higher dose. Both incidents were observed during medication pass observations and were corroborated by interviews with nursing staff and review of medical records. The facility's policy on the six rights of medication administration was not followed, resulting in significant medication errors for both residents.