Failure to Prevent Administration of Unnecessary and Contraindicated Medications
Penalty
Summary
A resident with multiple chronic conditions, including congestive heart failure, COPD, kidney disease, and paroxysmal atrial fibrillation, was admitted to the facility with documented allergies to several medications, including ceftriaxone and sulfa drugs. The allergy to ceftriaxone was noted in the electronic medical record (EMR), but the nurse entering the information did not review the specific reactions associated with each allergy, as these were listed on a different page of the hospital discharge summary. Subsequently, the nurse relied only on the top section of the summary and did not include the detailed reactions. The allergy information was transmitted to the pharmacy and appeared in the medication administration record (MAR), but the process for verifying and acting on this information was inconsistent among staff. During an acute episode of dyspnea, the nurse practitioner (NP) evaluated the resident and ordered ceftriaxone and azithromycin for pneumonia. The NP did not check the resident's allergies in the EMR before placing the order, and the nurse who signed off on the order also failed to verify allergies prior to obtaining and preparing the medication from the emergency kit. The pharmacy sent an alert regarding the ceftriaxone allergy, but because the medication was taken from the emergency kit, the alert did not prevent administration. The resident ultimately received the ceftriaxone injection from a different nurse, who also did not check the allergy information before administration. Interviews revealed that both the NP and nursing staff expected the other party to verify allergies, leading to a breakdown in the process. Additionally, the resident was prescribed azithromycin while already receiving amiodarone, a combination known to have a severe drug-to-drug interaction risk due to additive QT interval prolongation. The pharmacy sent an electronic alert about this interaction, which was acknowledged by the nurse without being read or acted upon. The nurse did not notify the provider or obtain a baseline EKG as would have been appropriate given the risk. The NP later confirmed that the combination was contraindicated and that she would have taken additional precautions if notified. The failure to read and respond to pharmacy alerts and to verify allergies before medication administration resulted in the resident receiving unnecessary and potentially harmful medications.