Significant Medication Error Due to Transcription Mistake
Penalty
Summary
A significant medication error occurred when a registered nurse transcribed a verbal order for divalproex sodium, a psychoactive medication, into the medical record of a resident for whom it was not intended. This error led to the resident receiving the medication in error 30 times over a period of approximately two weeks. The resident, who had a history of hip fracture and depression and was assessed as having moderate cognitive impairment, did not have symptoms of mood disturbances or behaviors that would have warranted the use of divalproex sodium. The error was identified through interviews and record reviews, which revealed that the medication order was meant for another resident. The facility's policy defines a medication error as the administration of a drug not in accordance with a physician's order, and specifically includes the administration of an unauthorized drug. The resident's records confirmed the administration of divalproex sodium without a valid indication or physician's order for this resident, as a result of the transcription error.