Significant Medication Error Due to Conflicting Orders and Inadequate Verification
Penalty
Summary
A resident with a history of fractured left femur, status post hemiarthroplasty, acute respiratory failure with hypoxia, and acute bronchitis due to RSV was admitted to the facility with two different Dilaudid (hydromorphone) orders from the hospital. The pharmacy received both orders, leading to confusion and the delivery of medication cards with conflicting dosing instructions. The medication administration record (MAR) and the medication card label did not match, and staff were instructed to follow the MAR if discrepancies arose. However, the medication card with the incorrect dose was not properly marked or removed, and staff did not consistently verify the most current physician order before administration. On the morning in question, an LPN administered 4 mg of hydromorphone to the resident for severe pain, after verifying the medication card label with the MAR. Shortly after, the resident was found to have abnormal, labored breathing and was difficult to arouse. Emergency medical services were called, and the resident was transferred to the hospital, where an opioid overdose was suspected and treated with Narcan. The facility's policies required staff to administer medications as prescribed, verify the six rights of medication administration, and observe and document the resident's response to PRN medications, but these procedures were not fully followed in this case. Interviews with staff revealed that there was confusion regarding which order to follow, and the process for reconciling discrepancies between the MAR and medication card was not consistently implemented. The medication card with the outdated order was not immediately marked to prevent administration, and staff did not always verify the most current physician order when discrepancies were identified. This series of actions and inactions resulted in the resident receiving a significant medication error, specifically an excessive dose of hydromorphone, leading to an adverse clinical event.