Duplicate Carvedilol Orders Result in Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, paroxysmal atrial fibrillation, and essential hypertension was administered duplicate doses of carvedilol due to the presence of two active orders for the medication in the Medication Administration Record (MAR). The MAR showed that both a 3.125 mg and a 6.25 mg carvedilol order were active, and staff administered multiple doses of 6.25 mg carvedilol on several consecutive days. The duplicate order was not discontinued when the new order was added, resulting in the resident receiving more medication than intended. Interviews with facility staff revealed that the Practitioner Assistant acknowledged there should have only been one active order for carvedilol and that the second order should have been discontinued. The Director of Nursing confirmed that staff administered duplicate doses over several days and explained that an alert system was in place to notify staff of duplicate orders, with the expectation that the nurse entering the order would verify and resolve any duplicates with the provider. The nurse responsible for entering the duplicate order stated she was multitasking and did not recall seeing the duplicate order alert.