Significant Medication Error Due to Incorrect Reconciliation of Antipsychotic Order
Penalty
Summary
A deficiency occurred when a resident with bipolar disorder was admitted to the facility and experienced significant medication errors due to inaccurate medication reconciliation. Upon admission, nursing staff transcribed the resident's hospital discharge orders for quetiapine incorrectly, resulting in the resident receiving 900 mg of quetiapine twice daily instead of the intended 900 mg once daily at bedtime. The error persisted for 25 days, during which the resident was administered a total daily dose that exceeded the usual recommended range. Nursing staff relied on the hospital discharge summary and medication list but failed to clarify the frequency of administration, despite noting that the dosage seemed excessive. The nurse did not consult further with the provider to confirm the correct order. The error was discovered when the resident became lethargic and exhibited unstable blood pressure and heart rate. Upon review, it was found that the quetiapine order had been duplicated and administered twice daily in error. The facility's policy required verification of medication orders and clarification with the provider if a dosage appeared excessive or unrelated to the resident's condition, but this process was not followed. The Director of Nursing stated that staff should have reviewed the psychiatric and provider notes to identify the discrepancy in the medication order.