Pharmacy Labeling Error Leads to Administration of Incorrect Opioid Medication
Penalty
Summary
A medication error occurred when a resident with a history of stroke, chronic pain, and ovarian cancer was administered oxycodone/acetaminophen instead of the hydrocodone/acetaminophen that was ordered by the physician. The error was traced to a pharmacy labeling mistake, where a blister package containing oxycodone/acetaminophen 5/325 mg was incorrectly labeled as hydrocodone/acetaminophen 5/325 mg. The tablets in the blister pack did not match the description on the pharmacy label, which was eventually noticed by nursing staff. The resident received a total of 18 doses of the incorrect medication over several days. The error was discovered when a nurse observed that the physical appearance of the pills did not match the label description. Upon further investigation, it was confirmed that the medication in the blister pack was not what was ordered. The pharmacy later determined that a technician had selected the wrong blister pack and the pharmacist failed to double-check the medication before it was dispensed to the facility. Interviews with the resident revealed that she did not experience adverse reactions but did report inadequate pain control during the period she received the incorrect medication. The incident was documented in the facility's records, and the physician was notified and assessed the resident. The pharmacy acknowledged the error and identified a breakdown in their verification process as the cause.