Failure to Follow Physician Orders Leads to Medication Errors
Penalty
Summary
The facility failed to prevent medication errors by not following physician orders during medication administration for a resident with multiple diagnoses, including asthma, hyponatremia, hypertension, gastro-esophageal reflux, osteoarthritis, and chronic kidney disease. During a medication pass, an LPN administered Losartan 50 mg instead of the physician-ordered Losartan 100 mg, and also gave two inhalations of Fluticasone Salmeterol ACT aerosol 500/50 mcg instead of the ordered one inhalation. The LPN signed off on the MAR as if the correct dosages had been administered, but a review of the medication bubble packages and the MAR revealed discrepancies in the number of tablets used and the dosages given. The LPN acknowledged the errors during the observation and confirmed that the medications were not administered as ordered. Further investigation showed that the process for handling discontinued medications was not followed, as the discontinued Losartan 50 mg package remained accessible in the medication cart instead of being removed and returned to the pharmacy. The facility's policy required that medication labels and MARs be compared before administration, and that any changes in orders be flagged and communicated to the pharmacy. However, these procedures were not adhered to, resulting in an 18.18% medication error rate during the observed medication pass.