Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 7.4% (2 errors out of 27 opportunities). One resident was observed receiving an incorrect dose of divalproex sodium and vitamin B-6. Specifically, the resident was administered three 250 mg tablets and one 500 mg tablet of divalproex sodium in the morning, totaling 1250 mg, despite physician orders specifying 750 mg in the morning and 500 mg in the evening. Additionally, the resident received a whole 100 mg tablet of vitamin B-6 instead of the ordered 50 mg, as only 100 mg tablets were available and the tablets were not scored for splitting. Interviews with nursing staff confirmed the administration of incorrect doses, and review of medication packets and physician orders corroborated the errors. The pharmacist identified that a previous order for divalproex sodium 500 mg twice daily had not been discontinued when a new order for three 250 mg tablets in the morning was received, leading to both doses being sent and administered together. Facility policy required medications to be administered as prescribed, prohibited splitting unscored tablets, and instructed staff to contact pharmacy for correct dosages, but these procedures were not followed.