Medication Administration Error Due to Pharmacy Mislabeling
Penalty
Summary
A resident with end stage renal disease and a history of kidney transplant was admitted and had a physician's order for Tacrolimus 0.5 mg capsule, an anti-rejection medication. However, due to a pharmacy error, a medication bubble pack containing Cialis 5 mg tablets was mislabeled as Tacrolimus and dispensed with the resident's name. Over a period of six days, the resident was administered Cialis instead of the prescribed Tacrolimus. The medical record did not show any order for Cialis for this resident. Licensed Practical Nurses confirmed administering the mislabeled medication, relying on the label and the five rights of medication administration, but failed to notice the discrepancy between the ordered capsule form and the tablet form present in the bubble pack. The error was only identified after several doses when another nurse questioned the form of the medication. The Director of Nursing and Consultant Pharmacist acknowledged the pharmacy's mislabeling and the failure of nursing staff to detect the error before administration, despite facility policies requiring verification of medication form and label against physician orders.