Incorrect Seroquel Dose Administered Due to Order and Label Discrepancy
Penalty
Summary
A Licensed Vocational Nurse (LVN) administered an incorrect dose of Seroquel to a resident diagnosed with schizophrenia. The resident was prescribed Seroquel 50 mg, with instructions to take one-half tablet by mouth every morning and at bedtime. However, during a medication administration observation, the LVN prepared and administered a full 50 mg tablet instead of the prescribed half tablet. The medication was provided in a bubble-pack containing only full tablets, and the pharmacy label instructed to give one full tablet twice daily, which did not match the physician's order. The LVN acknowledged the error, stating she failed to compare the medication label with the resident's current order and did not notice the discrepancy between the pharmacy label and the physician's order. The LVN also confirmed that the pharmacy had not received the updated order reflecting the decreased dose, resulting in the incorrect instructions on the medication packaging. The facility's policy requires staff to compare the medication and dosage on the Medication Administration Record (MAR) with the medication label and to verify with the physician's order if there are discrepancies, which was not followed in this instance.