Significant Medication Errors and Missed Doses Due to Staff Inaction and Process Failures
Penalty
Summary
A significant medication error occurred when a nurse administered a steroid medication, along with several other medications, to a resident for whom they were not prescribed. The nurse entered the resident's room, called him by another resident's name, and, after feeling overwhelmed and leaving the room to retrieve oxygen tubing, returned and administered the medications intended for a different resident. The error was discovered when the resident corrected the nurse about his name after receiving the medications. The nurse immediately notified the physician and Director of Nursing, and the resident was monitored closely. The resident was cognitively intact and had multiple diagnoses, including parkinsonism, diabetes, and chronic kidney disease. The medications administered in error included a steroid prescribed for another resident's pneumonia and COPD. Another deficiency involved a resident with diabetes and chronic pain who missed multiple doses of essential medications, including nerve pain medication, diabetic medication, and insulin. The facility failed to request a timely prescription for a controlled medication, resulting in a gap in administration. Additionally, nursing staff did not utilize available medication resources stored in the Pyxis automated dispensing system, despite the medications being present in the machine. Multiple nurses documented the unavailability of medications and did not retrieve them from the Pyxis, leading to missed doses. The resident reported experiencing pain due to the missed nerve pain medication and expressed frustration over the delay in receiving her medication. Interviews with staff and pharmacy personnel revealed that the refill process for the controlled medication was not initiated with sufficient time to avoid a lapse, and the pharmacy could not process the order without a prescription. The Pyxis system contained the necessary diabetic medications, but staff failed to check or utilize it, resulting in further missed doses. The facility's expectations were for staff to begin the refill process several days in advance and to be proficient in using the Pyxis system to prevent medication gaps.