Missed IV Antibiotic Dose Results in Significant Medication Error
Penalty
Summary
A resident with a medical history including infection and inflammatory reaction due to an internal joint prosthesis was prescribed intravenous Cefazolin 2g every 8 hours via a PICC line for prophylaxis. On observation, a full bag of IV Cefazolin was found hanging in the resident's room, not connected, and the resident was unsure if the morning dose had been administered. The resident reported not refusing the medication, and the IV access site was present and intact. Review of the physician's orders confirmed the requirement for timely administration of the antibiotic, and facility policy required medications to be administered as prescribed and in a timely manner. A Licensed Practical Nurse (LPN) confirmed that the 6:00am dose of Cefazolin had not been given and that there was no documentation in the electronic medical record explaining the missed dose. The LPN also stated that the physician should be notified of the missed dose. The infection preventionist later confirmed the resident did not refuse the medication and was unable to reach the nurse responsible for the missed administration. Facility policy emphasized the importance of timely medication administration, but this was not followed, resulting in a significant medication error for the resident.