Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Dosing
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by professional standards and facility policy. During the survey, two medication errors were identified out of 28 opportunities, resulting in a 7.14% error rate. The first error involved an LPN who prepared and dispensed a full 7.5 mg tablet of meloxicam for a resident, despite the physician's order specifying that only half a tablet (3.75 mg) should be administered. The error was only corrected after prompting, indicating a lapse in following the correct medication administration procedure. The second error involved a CNA-Med who dispensed Voltaren gel for a resident by measuring it directly into a medication cup, rather than using the manufacturer's dosing card as specified in the physician's order and the product's instructions. The CNA-Med incorrectly equated milliliters to grams and was unsure of the proper dispensing method. Upon review, it was found that the amount dispensed using the medication cup exceeded the correct dose as measured by the dosing card, confirming the error in administration. Interviews with the DON and the facility pharmacist confirmed that staff are expected to follow the seven rights of medication administration and use appropriate tools, such as dosing cards, to ensure accurate dosing. Both staff members involved failed to adhere to these standards, resulting in the administration of incorrect medication doses to residents.