Failure to Address Severe Drug Interaction Alert for Resident
Penalty
Summary
A nurse failed to protect a resident's right to be free from neglect by disregarding a severe drug-to-drug interaction alert sent from the pharmacy. The alert, which was triggered when a new antibiotic (azithromycin) was prescribed for a resident already taking amiodarone for abnormal heart rhythm, indicated a severe interaction risk due to additive QT interval prolongation. The nurse acknowledged the alert in the electronic medical record but did not read its contents or notify the physician about the potential interaction before administering the antibiotic. The resident involved had multiple significant medical conditions, including congestive heart failure, chronic obstructive pulmonary disease, lymphedema, kidney disease, paroxysmal atrial fibrillation, hypertension, and a history of transient ischemic attacks. The resident was cognitively intact and receiving oxygen therapy as needed. The new antibiotic was prescribed following an acute episode of dyspnea and a diagnosis of right lower lobe pneumonia. Interviews with facility staff, including the nurse, consultant pharmacist, DON, and medical director, confirmed that the nurse did not follow protocol for handling pharmacy alerts. The nurse believed it was the nurse practitioner's responsibility to check for allergies and contraindications and admitted to acknowledging the alert without reading it. The facility's policy, as described by the consultant pharmacist and DON, required nurses to read pharmacy alerts and notify the provider of any drug interactions before administering medications.