Resident Received 10x Prescribed Dose of Tacrolimus Due to Transcription Error
Penalty
Summary
A medication error occurred when a resident with a history of chronic myeloid leukemia, graft versus host disease, and bone marrow transplant was admitted to the facility with physician orders for Tacrolimus 0.5 mg daily. However, the medication was transcribed incorrectly by a registered nurse as Tacrolimus 5 mg daily, resulting in the resident receiving 12 doses at ten times the prescribed amount over a 12-day period. The error was not identified until the facility's pharmacy consultant discovered the discrepancy during a monthly medication regimen review. The resident's medication administration records confirmed that Tacrolimus 5 mg was administered daily from 3/31/25 to 4/11/25. Interviews with the Director of Nursing and the registered nurse responsible for the transcription confirmed the misreading and inaccurate transcription of the dosage. The resident reported feeling very sick and was subsequently hospitalized after experiencing symptoms including fatigue, headache, shortness of breath, and diarrhea. Laboratory results showed a Tacrolimus level at the threshold of toxicity during this period. The facility's policy required medications to be administered as prescribed, but this was not followed in this instance. The error was only identified after the pharmacy consultant's review, and the resident's condition required transfer to the hospital for further care. The incident was reported to the California Department of Public Health, which confirmed the administration of the incorrect medication dosage.