Medication Error Rate Exceeds Acceptable Threshold Due to Administration Failures
Penalty
Summary
A medication error rate of 9.68% was identified during medication administration observations, with three errors noted out of 31 opportunities involving three residents. In the first instance, a resident prescribed albuterol sulfate inhalation received the second puff only 10 seconds after the first, rather than waiting the recommended one minute between puffs. The nurse administering the medication was unaware of the required interval, and the facility's policy and national guidelines both specify a one-minute wait between inhalations. In the second case, a resident self-administered three puffs of budesonide-formoterol fumarate dihydrate inhaler instead of the two puffs ordered by the physician. The nurse did not provide instructions or verify the correct dosage with the resident before allowing self-administration. The facility's policy requires staff to explain the procedure and verify the correct medication, dosage, and administration method prior to administration. The third error involved a resident receiving five different medications via gastrostomy tube without water flushes between each medication. The nurse administered each medication sequentially without flushing the tube, contrary to facility policy, which requires a water flush between medications to ensure safe administration. The nurse stated that she was taught to mix medications with extra water but was not instructed to flush between medications, and the DON was unsure of the correct procedure.