Medication Administration Error Rate Exceeds 5% Due to Multiple Errors
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as required. During an observation of medication administration for one resident, a total of twelve medication opportunities were reviewed, and three errors were identified, resulting in a 25% error rate. The errors included the administration of saccharomyces boulardii instead of the ordered lactobacillus probiotic, failure to wait the recommended interval between administering two different types of eye drops (latanoprost and timolol) in the same eye, and the administration of both eye drops consecutively without the required waiting period. The staff member involved confirmed the administration of the incorrect probiotic and did not follow the recommended procedure for eye drop administration. The resident involved had a history of diabetes mellitus and recent eye surgery, with orders for multiple oral medications, eye drops for glaucoma, and insulin. The medication administration record showed that the resident was to receive lactobacillus, but this was substituted with saccharomyces without a corresponding order at the time of administration. Additionally, the facility did not have a policy or procedure in place for the administration of eye drops, and staff were not following best practices for timing between different ophthalmic medications. These actions and omissions led to the identified medication errors.