Duplicate Proton Pump Inhibitor Therapy Administered Without Clinical Justification
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications when two proton pump inhibitors (PPIs), pantoprazole 40 mg in the morning and omeprazole 20 mg at bedtime, were ordered and administered daily for the same indication of gastroesophageal reflux disease (GERD). Review of the resident’s medical record and Medication Administration Record (MAR) showed both medications were given concurrently from March 22 through April 23, with no documented clinical rationale for the duplicate therapy. The orders for both PPIs were initiated on the same date, and the administration was verified by the Director of Nursing (DON), who acknowledged that both drugs are from the same therapeutic class and have similar mechanisms of action. The facility’s Consultant Pharmacist (CP) confirmed that he had not reviewed these medications since they were ordered after his last medication regimen review. The CP stated he would have questioned the duplicate use and recommended discontinuing one of the PPIs if there was no clinical justification. Facility policy requires staff to contact the prescriber if a medication is believed to be inappropriate or excessive, but there was no evidence this was done. Prescribing information and national guidelines indicate that the two PPIs are considered equivalent for GERD treatment and that there is no benefit to administering both simultaneously.