Medication Order Transcription Error Resulting in Incorrect Ibuprofen Administration
Penalty
Summary
The facility failed to ensure accurate transcription of physician orders for a resident with a history of stroke and aneurysm, resulting in a medication error. The resident was prescribed ibuprofen 400 mg every 6 hours as needed (PRN) for pain or fever, but the order was incorrectly transcribed into the electronic health record (EHR) as a scheduled dose every 6 hours. As a result, the resident received ibuprofen 66 times over a period of approximately two weeks, rather than only as needed. The medication administration record (MAR) reflected the incorrect scheduled dosing, and staff administered the medication according to the MAR. The error was identified as a human transcription error, with the health unit coordinator entering the order, the charge nurse checking it, and nursing staff administering the medication based on the MAR. The facility's medication error report noted that the physician and family were not notified in a timely manner, and the resident's record did not document whether the resident experienced any untoward effects from the medication. Interviews with staff confirmed the process and the error, and the facility's policy required prompt reporting, observation for effects, and notification of the physician and family, which was not fully followed in this case.