Failure to Accurately Transcribe and Double-Check Admission Medications Resulting in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a newly admitted resident's medications were incorrectly transcribed and not properly double-checked according to facility procedures. The resident, who had a history of cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease, was admitted for respite care and was ambulatory and alert at the time of admission. The hospital discharge orders specified Carbidopa/Levodopa to be given five times daily and Levothyroxine once daily, but these frequencies were transposed during the admission process. As a result, the resident received Levothyroxine five times daily and Carbidopa/Levodopa only once daily. Multiple staff interviews and record reviews revealed that the medication orders were entered by a unit manager and were supposed to be double-checked by a second nurse, but there was no documentation or confirmation that this double-check occurred. Several nurses and the pharmacist involved in the process either assumed the orders were correct or did not verify the original admission paperwork. The error persisted for several days, with the resident receiving excessive doses of Levothyroxine, totaling 2800 mcg over a 96-hour period. The facility's process lacked a formal policy or checklist for verifying new admission medication orders, and staff relied on informal practices that failed to prevent the error. The resident's condition deteriorated during the stay, with documented confusion, fever, tachycardia, and lethargy. The error was eventually discovered after the resident exhibited significant changes in condition, including increased confusion and abnormal vital signs. The facility's medical staff and hospice personnel confirmed that the medication error led to a thyroid storm, and the resident was discharged in a significantly worsened state, ultimately passing away at home shortly after discharge. The facility's documentation and interviews confirmed that the medication transcription error was not identified or corrected in a timely manner, and the required verification steps were not properly followed.