Significant Medication Error Due to Transcription Mistake
Penalty
Summary
A deficiency occurred when a resident with diagnoses including atrial fibrillation, protein calorie malnutrition, dementia, depression, and transient ischemic attacks was prescribed Diltiazem 180 mg daily by their primary care provider. However, facility staff transcribed the order incorrectly, entering Dilantin 180 mg instead of Diltiazem into the resident's medication orders. As a result, the resident received Dilantin 180 mg rather than the intended Diltiazem on the following day. The error was identified through a review of the medical record, medication administration record, and the facility's medication error form, which confirmed the transcription mistake. The facility's policy required medications to be administered as prescribed, but this was not followed in this instance, leading to the administration of the wrong medication to the resident.
Plan Of Correction
Resident was assessed for changes in condition and any side effects from the medication and none were noted. Assessment was completed by RN unit manager and evaluated by LPN staff nurses on 4/25/25. No new interventions needed. The physician was notified on 4/25/25 and no new orders provided. There was no change in the resident's condition. The facility DON and/or designee completed an audit of orders for patients on Dilantin and/or Diltiazem to ensure that orders are correct. The audit was completed on 6/26/25. All nurses in the facility will be educated on ensuring that appropriate medication is picked from the drop-down box in the EMR and to be aware of look-alike names such as Dilantin and Diltiazem. Education will be completed by DON and/or designee and will be completed by 7/10/25. The DON and/or designee will audit new medication orders on 2-3 residents per unit weekly for 4 weeks. The results of the audit will be forwarded to the QAPI Committee to determine next steps.