Significant Medication Error: Incorrect Form of Isosorbide Mononitrate Administered
Penalty
Summary
Licensed nursing staff failed to ensure a resident was free from significant medication errors when they administered the incorrect form of isosorbide mononitrate. The staff crushed and administered an extended-release (ER) tablet of isosorbide mononitrate 30 mg via g-tube instead of the prescribed immediate-release (IR) form on 14 occasions. This error occurred over a two-week period and was not identified by the nursing staff during medication administration, despite the facility's policy requiring comparison of the physician's order, pharmacy label, and medication administration record. The resident involved had multiple complex medical conditions, including hemiplegia, hemiparesis following cerebral infarction, dementia, dysphagia, schizophrenia, and a gastrostomy tube. The resident was entirely dependent on staff for activities of daily living and had severely impaired cognitive skills. The medication order specified isosorbide mononitrate 30 mg via g-tube daily for hypertensive heart disease, but only the ER form was supplied and administered. Both the pharmacy and nursing staff failed to recognize the discrepancy between the physician's order and the medication supplied. The pharmacy delivered only the ER form, stating the IR form was not available, and did not communicate this to the facility. Nursing staff did not clarify the order with the physician or pharmacy, and multiple nurses administered the ER medication in crushed form, contrary to standard practice and facility policy. The Director of Nursing confirmed that these actions did not follow expected procedures and placed the resident at risk.