Significant Medication Error Due to Incorrect Order Entry
Penalty
Summary
A deficiency occurred when a resident admitted for respite care under hospice services received several medications as routine doses rather than as needed (PRN), contrary to the physician's orders. The resident's orders included morphine, Lomotil, and Tums, all intended to be administered PRN for specific symptoms such as shortness of breath, severe pain, diarrhea, or gastroenteritis. However, due to an error by the admitting nurse, these medications were entered into the electronic medical system as scheduled routine medications. As a result, the resident received morphine and Lomotil at scheduled times despite not exhibiting symptoms that warranted their use, such as pain, shortness of breath, or diarrhea. Documentation confirmed that the resident was not experiencing these symptoms at the time the medications were administered. Following the administration of these medications, the resident experienced adverse effects, including nausea and vomiting, which required the administration of Zofran to manage the symptoms. Interviews with facility staff and the hospice nurse confirmed that the medication orders had been incorrectly entered and administered, and the error was identified after the resident developed side effects. The facility's policy required medications to be administered according to the prescriber's orders, which was not followed in this instance, resulting in a significant medication error.