Failure to Discontinue Previous Acetaminophen Order Resulted in Excessive Dosage
Penalty
Summary
A deficiency occurred when a resident with chronic pain syndrome, osteoarthritis, and type 2 diabetes mellitus with diabetic neuropathy received excessive doses of acetaminophen due to a failure to discontinue a previous medication order. The resident had an active care plan for pain management, and her physician initially ordered acetaminophen extended release 650 mg three times daily, not to exceed 3,000 mg in 24 hours. Subsequently, a new order was written for acetaminophen 1,000 mg twice daily, but the previous order was not discontinued, resulting in a combined daily dose of 3,950 mg. The medication administration record confirmed that both acetaminophen regimens were administered concurrently over a period of time. The error was traced to the Unit Manager, who entered the new order but did not discontinue the previous one, citing oversight. The facility's process for order entry and verification was not followed, as the second nurse check was omitted when the Unit Manager entered the order herself. This lapse allowed the duplicate orders to remain active and be administered to the resident. Interviews with pharmacy consultants, the nurse practitioner, and the DON confirmed that the recommended maximum daily dose of acetaminophen for elderly residents is 3,000 mg, and the error was not detected until after the resident had received the excessive dosage. The pharmacy's monthly review process did not identify the issue until after the orders had been corrected. The DON and Medical Director were unaware of the duplicate orders until after the incident, and the facility's standard procedures for order reconciliation and verification were not properly executed in this case.