Medication Administration Error: Incorrect Levetiracetam Dosage Prepared
Penalty
Summary
A deficiency occurred when a registered nurse (RN) prepared to administer Levetiracetam to a resident for seizure control. The physician's order specified a dose of 1250 mg every 12 hours, to be given as one 750 mg tablet and one 500 mg tablet. During medication administration, the RN placed two 750 mg tablets in the medication cup, totaling 1500 mg, which exceeded the prescribed dose. The error was identified before the medication was given, after the RN was prompted to review the order and the medication card, which detailed the correct tablet combination. The facility's medication administration guidelines require verification of the medication three times: when pulling the medication from the cart, when preparing the dose, and before administration. Both the unit manager and the executive director of nursing stated their expectations that nurses administer medications exactly as ordered and are able to calculate correct dosages. The incident was observed during a medication pass and confirmed through interviews and record review.