Medication Order Transcription Error Leads to Incorrect Aspirin Administration
Penalty
Summary
A deficiency occurred when a physician's order for Aspirin 81 mg to be administered twice a week was incorrectly transcribed as a daily order for a resident with atrial fibrillation. The hospital discharge summary specified the correct dosing frequency, but during the admission process, a registered nurse transcribed the order into the electronic medical record as a daily dose. The medication was then administered daily for five consecutive days, rather than the intended twice-weekly schedule. The error was not identified until after the resident was discharged, when a medication incident report was completed. Interviews revealed that the nurse responsible for transcribing the order did not re-check the order before confirming it in the EMR and assumed her preceptor would review her work. The preceptor, who was orienting the nurse, did not verify the accuracy of the transcribed order. The Director of Nursing Services confirmed that the facility's process requires a second nurse to review and confirm new orders in the EMR, but this second check was not completed, resulting in the medication error.