Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 9.52%, which exceeds the acceptable threshold of 5%. During medication administration observations, three errors were identified out of 43 opportunities involving three residents. In one instance, a nurse administered Robitussin DM, which contains both guaifenesin and dextromethorphan, instead of the prescribed plain Robitussin (guaifenesin only) to a resident with allergy and cough symptoms. The nurse could not locate the correct medication and used a similar product from another unit without clarifying the order with the physician. Another error involved the administration of a laxative containing only Senna to a resident, despite the physician's order specifying a combination of Senna and Docusate. The nurse attributed the mistake to the similar appearance of the medication bottles. In a third case, a nurse applied a lidocaine 4% patch to a resident for pain management, although the order specified a 5% strength patch. The nurse documented the administration as 5% on the Medication Administration Record. The facility's policy requires medications to be administered according to prescriber orders and verified for the correct resident, medication, and dosage, but these procedures were not followed in the observed cases.