Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Incorrect Medication Administration
Penalty
Summary
A medication error rate of 7.14% was identified during survey observations, with two errors out of 28 opportunities involving two residents. In the first instance, a Licensed Vocational Nurse (LVN) failed to administer Chlorhexidine Gluconate Oral Rinse to a resident as ordered. The nurse confirmed during interview that the medication had not been available since the order was placed several days prior, resulting in the resident not receiving the prescribed oral rinse. In the second instance, another LVN administered insulin aspart (Novolog) to a resident instead of the ordered insulin lispro (Humalog) before lunch, following a sliding scale for blood glucose management. The nurse stated she believed the two insulins were equivalent and administered the available medication without obtaining a new physician order. The facility's consultant pharmacist confirmed that the two insulins are different medications and a new order is required for substitution. The facility's policy requires medications to be administered in accordance with prescriber orders.