Significant Medication Error: Crushing of Extended Release Potassium Chloride
Penalty
Summary
A Qualified Medication Aide (QMA) was observed preparing and administering medications for a resident who required her medications to be crushed. During the process, the QMA included a 20 mEq Extended Release (ER) Potassium Chloride tablet among the medications to be crushed. The QMA removed a soft gel vitamin supplement, noting it could not be crushed, but proceeded to crush the remaining medications, including the ER Potassium Chloride tablet, and administered them to the resident with pudding. The QMA later acknowledged that some medications should not be crushed due to their coating and referred to a 'do not crush' list on the medication cart, which specifically included the ER Potassium Chloride tablet. She was unaware at the time of administration that this medication should not be crushed. The resident involved was severely cognitively impaired and had diagnoses including coronary artery disease, hypertension, and malnutrition. A review of the resident's most recent laboratory values showed her potassium level was within normal limits. The facility's 'Medications Not To Be Crushed' list, last revised in December 2022, confirmed that the ER Potassium Chloride tablet should not be crushed due to its extended-release formulation.