Unnecessary Psychoactive Medication Administered Due to Transcription Error
Penalty
Summary
A resident was administered divalproex sodium (Depakote), a psychoactive medication, without appropriate indications for use. The resident's medical record showed a diagnosis of hip fracture and depression, but there were no documented symptoms of mood disturbances or behavioral issues that would warrant the use of a mood stabilizer. The Minimum Data Set assessment indicated moderate cognitive impairment, but did not support the need for psychoactive medication. The medication was ordered for 'mood instability,' which was not recognized as a valid diagnosis for such treatment. The error occurred when a registered nurse transcribed a verbal order for divalproex sodium intended for another resident into this resident's medical record. The nurse did not read the order back to the physician as required by facility policy, resulting in the medication being administered to the wrong resident for two weeks. The facility's policies require that verbal orders be read back to the practitioner to ensure accuracy, and that informed consent be obtained from the resident or responsible party prior to administering psychotropic medications. In this case, no consent was obtained. The facility's pharmacy consultant identified the lack of an appropriate diagnosis and requested clarification from the prescribing physician. Documentation confirmed that the medication was given without a valid indication and that the error was due to a communication mistake. Facility policies also define medication errors to include the administration of unauthorized drugs and emphasize the importance of following clinical guidelines and ensuring the right patient receives the correct medication.