Significant Medication Error Due to Misapplied Fentanyl Patch Orders
Penalty
Summary
A significant medication error occurred when a resident was found to have two 50mcg Fentanyl patches applied, despite medication orders specifying the use of either one 50mcg patch or two 25mcg patches only if the 50mcg patches were unavailable. The resident subsequently exhibited increased confusion, including not recognizing her husband and displaying unusual behavior at mealtime. Review of the medication administration record showed the order for two 25mcg patches was only documented as given once, with all other opportunities marked as not applicable, while the 50mcg patch was the standard order. The medication orders were entered with the expectation that staff would understand the conditional use of the two 25mcg patches, but this was not clearly communicated, leading to the error.