Medication Error Rate Exceeds 5% Due to Incorrect Dosage Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 30 observed opportunities, resulting in a 6.67% error rate. In the first instance, a resident with a diagnosis including vitamin deficiency had a physician's order for Cholecalciferol (Vitamin D3) 50 mcg (2000 units) once daily. During medication administration, the nurse provided only one tablet of Vitamin D3 25 mcg instead of the prescribed dose. The nurse later acknowledged that she should have administered two tablets to meet the ordered dosage. In the second instance, another resident with vitamin D deficiency had an active order for Cholecalciferol (Vitamin D3) 50 mcg (2000 units) once daily. The nurse administered two tablets of Vitamin D3 10 mcg (400 units) instead of the correct formulation, resulting in an incorrect total dose. The nurse admitted awareness of the two different Vitamin D3 formulations available and recognized that she should have selected the correct bottle to provide the ordered dose. In both cases, the DON indicated that the errors likely occurred because the nurses did not read the medication labels carefully, despite the expectation to follow the five rights of medication administration.