Medication Error Rate Exceeds Threshold Due to Improper Crushing and Mixing of Medications
Penalty
Summary
A medication error rate of 7.4 percent was identified during a survey, exceeding the required threshold of less than five percent. Specifically, two medication errors were found out of 27 opportunities, involving one resident who had diagnoses including gastroesophageal reflux, hypothyroidism, and thoracic spine pain. The errors occurred when a nurse crushed and combined Levothyroxine and Hydrocodone-Acetaminophen together for administration, despite physician orders specifying that each medication must be prepared individually if more than one is to be administered. Observation of the medication administration process revealed that the nurse placed both medications in a single pouch, crushed them together, mixed them with applesauce, and administered the mixture to the resident. The nurse stated that mixing medications was acceptable if there was an order, but review of the facility's policy and the physician's orders confirmed that medications should be prepared separately. The Director of Nursing acknowledged that the facility did not follow its own policy regarding medication administration.