Significant Medication Error Due to Incorrect Transcription of Chemotherapy Orders
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and multiple diagnoses, including dysphagia, epilepsy, and neurocognitive disorder with Lewy bodies, was readmitted to the facility. The resident required substantial assistance with daily activities and had a care plan that included medication review and administration per physician order. Upon readmission, the hospital discharge summary specified hydroxyurea dosing by gastrostomy tube with different doses and frequencies for specific days of the week. However, the nurse supervisor responsible for entering the hospital discharge orders into the electronic medical record (EMR) failed to accurately transcribe the hydroxyurea orders. Instead of entering the correct number of doses per day as specified, the nurse entered significantly higher doses—three times the intended dose on some days and four times on others. The facility physician signed off on these orders, believing them to be accurate, and the error was not detected during the verification process. As a result, the resident received a total of 41,000 mg of hydroxyurea over a 14-day period, which was 30,000 mg in excess of the hospital's order. This overdose led to a critical decline in the resident's white blood cell and platelet counts, resulting in a change of condition that required hospitalization. The resident was admitted to the hospital with neutropenic fever and multiple infections, and laboratory results confirmed critically low blood counts. Interviews with facility staff and review of facility policy revealed that the required process for transcription and verification of medication orders was not properly followed, and the facility was unable to provide a policy specifically addressing the transcription/verification process.