Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Order Discrepancies
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with two errors identified out of 31 observed opportunities, resulting in a 6.45% error rate. One resident, who had significant medical conditions including hemiplegia, hemiparesis, dementia, dysphagia, and a gastrostomy tube, was prescribed isosorbide mononitrate 30 mg to be administered via g-tube. However, the pharmacy supplied only the extended-release (ER) form of the medication, which was not intended to be crushed or administered via g-tube unless specifically ordered. Nursing staff failed to notice the discrepancy between the physician's order and the medication label, and proceeded to crush and administer the ER tablets via g-tube on multiple occasions. Both the pharmacy and nursing staff did not communicate or clarify the order, and the error persisted over several administrations. Another resident, with diagnoses including diabetes mellitus, gastrointestinal hemorrhage, and schizoaffective disorder, was prescribed metformin 1000 mg to be given with food or a meal. During medication administration, the nurse attempted to give the metformin without ensuring the resident had food, contrary to the physician's order. The nurse acknowledged the error and recognized that the medication should have been administered with food to align with the order and prevent potential gastric upset. The facility's policy required licensed nurses to perform three checks—comparing the physician's order, pharmacy label, and medication administration record—prior to administering medications, and to resolve any discrepancies before proceeding. In both cases, the required checks were not properly performed, and medications were administered in a manner inconsistent with physician orders, directly contributing to the identified medication errors.