Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
A medication error rate of 9.09% was identified during a survey observation of medication administration for one of seven residents. The registered nurse (RN) prepared medications for a resident, including potassium chloride and vitamin D3, but initially selected incorrect doses—two potassium tablets instead of one, and one vitamin D3 tablet instead of the ordered two. The error was identified only after the surveyor intervened and asked the RN to review the prepared medications. Additionally, the RN prepared and included oxybutynin, a medication not currently ordered for the resident, in the medication cup. The RN admitted she was working too quickly and was unsure if she would have caught the errors without the surveyor's intervention. The facility's policy required staff to compare the medication listed on the resident's Medication Administration Record (MAR) with the medication container label at three separate points and to follow the eight rights of medication administration. The RN did not adhere to these procedures, as evidenced by the preparation of incorrect doses and the inclusion of a medication not listed on the MAR. The director of nursing confirmed that staff are expected to closely check the MAR and medication bottles to prevent such errors.