Failure to Administer Ordered Sodium Chloride Results in Critical Medication Error
Penalty
Summary
A resident with diagnoses including permanent atrial fibrillation, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), chronic kidney disease, and malignant neoplasm of the bladder was admitted to the facility with hospital discharge orders for sodium chloride 1gm PO QID. Upon review, there were no physician orders entered for sodium chloride, nor was there any evidence on the medication administration record that the resident received sodium chloride during the entire stay at the facility. The nurse practitioner’s note indicated that sodium chloride was necessary for the management of SIADH, and the expectation was that the medication was being administered as ordered. Interviews with facility staff revealed that the admission nurse was responsible for entering the orders and that a second nurse was supposed to double-check the orders for accuracy. However, both the initial entry and the double-check failed to identify the omission of the sodium chloride order, resulting in the resident not receiving the prescribed medication. As a result of not receiving sodium chloride, the resident developed a critically low sodium level, became confused, and experienced hallucinations. The resident was subsequently hospitalized for 15 days to correct the sodium imbalance. Hospital records confirmed a sodium level of 115, which was identified as a critical lab value. The facility’s policies required accurate transcription and administration of physician’s orders, but these procedures were not followed in this case.