Failure to Separate Administration of Iron and Calcium Supplements
Penalty
Summary
The facility failed to ensure the effective use of medications for a resident diagnosed with anemia by administering ferrous sulfate (iron supplement) and calcium at the same time each day. The resident had physician orders for both medications to be given at 9 a.m., and this practice began when the calcium order was started. Clinical record review confirmed that both medications were administered concurrently since the initiation of the calcium order. During an interview, the pharmacy consultant confirmed that ferrous sulfate and calcium should be administered at least two hours apart due to a significant drug-drug interaction that decreases iron absorption. Reference to Lexicomp, a nationally recognized drug information resource, indicated that co-administration of these medications can decrease iron absorption by an average of 60%. The facility's policy required the pharmacy to screen for drug interactions with each new medication order, but this was not effectively implemented in this case.