Crushing of Extended-Release Medication Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with diagnoses including reduced mobility, cardiac pacemaker, history of sudden cardiac arrest, Alzheimer's disease, and heart failure was administered metoprolol succinate extended-release in a crushed form. The resident's care plan indicated that medications could be crushed to aid swallowing, and the medication aide prepared and intended to administer several medications, including the extended-release metoprolol, in crushed form. The aide stated she had been crushing this medication for some time, assuming it was permissible due to the general order to crush medications, and did not notice the warning label on the medication card indicating it should not be crushed or chewed. Further interviews revealed that nursing staff were unaware that the extended-release formulation should not be crushed and had not verified this with the provider. The nurse practitioner, when contacted, confirmed that the medication should not be crushed and changed the order to a different formulation. The director of nursing acknowledged that extended-release medications should not be crushed unless specifically ordered and that it was the facility's responsibility to notify the provider if a medication needed to be changed to a crushable form. The facility's policy on crushing medications was requested but not provided.