Medication Administration Error: Incorrect Lyrica Dosage Given
Penalty
Summary
A medication administration error occurred when a nurse failed to ensure the correct dosage of Lyrica was given to the correct resident. One resident with severely impaired cognition, who was prescribed Lyrica 25 mg twice daily, was instead given a 100 mg dose intended for another resident. The error was discovered during a narcotic count, which revealed that the 25 mg dose had not been removed from the correct resident's blister pack, while two 100 mg pills had been removed from the other resident's pack. The nurse involved could not recall if the correct medication was administered and admitted to not checking the medication label before giving the dose. The medication administration record indicated that the medication was provided, but did not note the error. The nurse self-reported the discrepancy after discovering it during the narcotic count and assessed the affected resident, who showed no adverse effects and maintained stable vital signs throughout the monitoring period. Interviews with facility staff, including the DON and Medical Director, confirmed the sequence of events and the nurse's failure to verify the medication label before administration. The incident involved two residents with different cognitive statuses and medication regimens, and the error was identified through routine medication count procedures rather than at the time of administration.