Incorrect Transcription of Medication Order Led to Overmedication
Penalty
Summary
A resident with diagnoses including anemia in chronic kidney disease, chronic obstructive pulmonary disease, and type 2 diabetes was admitted to the facility. Upon admission, the resident's hospital discharge instructions specified cyclobenzaprine 10 mg, to be taken orally as one tablet three times a day as needed for spasms. However, the medication order transcribed into the facility's records incorrectly stated to administer three tablets by mouth every eight hours as needed. This transcription error resulted in the resident receiving an incorrect, higher dose of cyclobenzaprine on multiple occasions, as documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for both February and March. The error persisted until the medication order was corrected in March, after which the resident received the medication as prescribed. The Director of Nursing confirmed that the order was transcribed from the hospital discharge instructions and reviewed by both pharmacy and nursing staff, but acknowledged the error and stated the resident was overmedicated. Facility policy required that admission orders be reviewed with the physician and transcribed based on discharge instructions, but this process failed to prevent the medication error in this instance.