Medication Error: Administration of Unnecessary Drug Due to Order Transcription Mistake
Penalty
No penalty information released
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Summary
A resident with a history of mood disorder, depression, and anxiety was admitted to the facility and later evaluated by a psychiatrist, who intended to prescribe hydroxyzine for anxiety. However, due to a transcription or communication error, hydralazine—a medication used for hypertension and heart failure—was ordered and subsequently administered to the resident for anxiety. The medication administration record confirmed that the resident received hydralazine 50 mg every 8 hours for anxiety over a period of approximately 11 days, totaling 34 doses. This error was confirmed through interviews with both the psychiatrist and the Director of Nursing, who acknowledged that the resident was given hydralazine instead of the intended hydroxyzine.