Pharmacist Failed to Identify Excessive Antibiotic Dosing During Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the monthly drug regimen review (MRR) conducted by the consultant pharmacist identified and reported medication irregularities for one resident. Specifically, the pharmacist did not detect or report that the resident received an excessive number of doses of the antibiotic Flagyl, exceeding the intended duration as specified in the hospital discharge summary and physician's orders. The resident, who had a history of pyelonephritis and renal and perinephric abscess, was prescribed Flagyl for a specific number of doses, but the medication administration record showed that the resident received 127 doses instead of the intended 90. The facility's policy required the pharmacist to thoroughly review medical records to identify and report medication irregularities, such as medications ordered in excessive doses or without clinical indication. Despite this, the pharmacist did not identify the discrepancy between the number of days and doses in the order, nor did she report it as an irregularity. Interviews with facility staff, including the consultant pharmacist, regional nurse, and DON, confirmed that the MRR process should have detected and reported this issue, but it was missed during the monthly reviews.