Significant Medication Errors in Medication Administration and Ordering
Penalty
Summary
A significant medication error occurred when a nurse entered a prescription for fluoxetine for a resident who was not intended to receive it. The error happened because the nurse confused two hospice residents with similar initials while processing physician orders. As a result, the resident received 24 doses of fluoxetine over nearly two weeks before the mistake was discovered. The resident's family was notified after the error was identified, and the nurse acknowledged the mistake during an interview. Additionally, the same resident did not receive a prescribed fentanyl patch for pain management as ordered. The medication was out of stock, and the patch was not applied for several days. Documentation shows that the pharmacy was awaiting provider approval for the refill, and a verbal order to hold the patch was entered by a nurse without direct communication with the physician. The resident's family and ARNP were updated about the situation, and progress notes indicated that the resident went without the patch during this period. Interviews with staff revealed inconsistencies in the medication ordering and reordering process, including uncertainty about whether the patches had been reordered and a lack of clarity regarding the use of the emergency kit. The facility did not have a specific policy related to medication errors, instead relying on standards of practice. The resident involved had multiple complex medical conditions, including cancer, hypertension, peripheral vascular disease, COPD, malnutrition, depression, and chronic pain, and was receiving hospice services at the time of the deficiencies.