Failure to Follow Five Rights of Medication Administration Leads to Significant Methadone Overdose
Penalty
Summary
Facility staff failed to follow the five rights of medication administration for a resident with multiple complex medical conditions, including Multiple Sclerosis, paraplegia, and chronic pain. The staff did not compare the written order on the Medication Administration Record (MAR) with the prescription label on the Methadone bottle before administration. As a result, the resident received five times the prescribed dose of Methadone over the course of three days, totaling nine incorrect administrations. The error occurred because staff administered Methadone based on outdated or incorrect information, specifically using the concentration and dosing instructions from a discontinued medication bottle rather than the current prescription. Multiple nurses, including agency staff, RNs, and LPNs, administered the incorrect dose, each failing to verify the medication concentration and dosage as indicated on the new prescription bottle. The MAR and narcotic record contained conflicting information, and staff relied on these records without cross-checking the actual medication label, leading to repeated overdoses. The resident experienced a significant decline following the medication errors, including impaired speech, inability to verbalize needs, decreased oral intake, lethargy, and increased weakness. Observations and interviews with staff and the resident's significant other confirmed these changes, noting that the resident was previously able to speak and eat but became largely nonverbal and unable to tolerate food or oral medications after the errors. The medication error was discovered during a medication count, and subsequent interviews revealed that staff had not recognized the change in medication concentration or the impact of the error until the resident's condition had significantly deteriorated.
Removal Plan
- Provide education to nurses on medication administration and transcription, the five rights of medication administration, ensuring medication labels match physician orders, and contacting pharmacy or physician for clarification.
- Educate all nurses on medication types, prevention of errors, high risk medications, and compliance with national safety standards.
- Review pain medication management for accuracy and ensure the label on the bottle matches the physician order in the medical record.
- Review orders and liquid medication labels for all like residents to ensure labels on bottles match the orders in the medical record.
- Initiate compliance audits.