Failure to Prevent Significant Medication Error Due to Improper Order Entry and Administration
Penalty
Summary
A significant medication error occurred when a nurse failed to enter a provider's verbal order for an antibiotic (Rocephin 1 gm IM) into the electronic medication administration system (Point Click Care) and did not administer the medication as ordered. Instead, the nurse administered Ceftriaxone 2 gm/Dextrose 50 ml via the clysis system, which was not ordered for the resident. Additionally, the nurse used medication that was prescribed for another resident, which had been discontinued and was awaiting return to the pharmacy. The nurse also failed to complete the required documentation for a change in condition and did not place the resident on alert charting as required by facility policy. The resident involved was moderately cognitively impaired and had multiple diagnoses. Review of the resident's medication administration records showed no antibiotic order was present at the time of administration. The facility's policies required that all medication orders, especially verbal orders, be immediately and accurately recorded in the resident's medical record, including all necessary details such as drug name, strength, dosage, route, and frequency. The nurse did not follow these procedures, resulting in the administration of an unprescribed medication and lack of proper documentation.