Medication Error: Double Dosing of Temazepam Due to Failure to Follow Verification Protocol
Penalty
Summary
A medication error occurred when a resident with chronic kidney disease stage 3, hypertension, and muscle weakness received two doses of temazepam 15 mg within a short interval, contrary to the prescriber's order of one capsule by mouth every 24 hours as needed for insomnia. The resident's Minimum Data Set indicated intact cognition and a need for partial to moderate assistance with activities of daily living. The error took place when one nurse administered temazepam to the resident after a complaint of insomnia, and a second nurse, a few hours later, also administered the same medication after the resident again reported difficulty sleeping. The second nurse relied on the resident's statement that no sleep medication had been given previously and proceeded to administer the dose, only discovering the error when the electronic charting system (Point Click Care) alerted her that the previous dose had been given too recently. Facility policy required nurses to check the electronic charting system before administering controlled medications to ensure correct timing and prevent errors. Both the second nurse and the Director of Nursing confirmed that the correct process was not followed, as the medication was administered and documented on the controlled drug record before verifying in the electronic system, resulting in the resident receiving two doses within a two-hour and twenty-four-minute interval.