Significant Medication Error Due to Incorrect Transcription of Lasix Order
Penalty
Summary
A significant medication error occurred when a nurse incorrectly transcribed and administered Lasix at a higher dose than prescribed for a resident with a history of atherosclerotic heart disease and severe cognitive impairment. The nurse practitioner had ordered an increase in Lasix to 40 mg by mouth daily, communicated via encrypted text to the charge nurse. However, the registered nurse entered the order as Lasix 40 mg twice a day instead of the intended once daily dose. This discrepancy resulted in the resident receiving double the prescribed amount of Lasix. The error was identified when the nurse practitioner reviewed the resident's medication regimen and discovered the incorrect dosing. The Director of Nursing confirmed that the facility's process involved the nurse practitioner sending orders via encrypted text to the charge nurse, who then entered them into the system without additional oversight. The administrator acknowledged the transcription error and recognized the need for improved verification and communication of medication orders.