Excessive Administration of Antibiotic Due to Order Transcription Error
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the administration of the antibiotic Flagyl. The resident, who had a history of pyelonephritis and renal and perinephric abscess, was admitted with a hospital discharge summary indicating a prescription for Flagyl to be given three times daily for a total of 90 doses. However, the physician’s order was transcribed to include both a duration of 89 days and 90 doses, leading to confusion. As a result, the resident received 127 doses of Flagyl, exceeding the intended 90 doses by 37. Review of the medication administration records confirmed the excessive administration, and there was no documentation in the progress notes that a provider had been consulted to extend the duration of the medication. Interviews with facility staff, including the physician, regional nurse, and DON, revealed that the error stemmed from the conflicting information in the order regarding both days and doses, and no one recalled authorizing the extended duration.