Significant Medication Error Due to Improper Administration via PEG Tube
Penalty
Summary
A resident with diagnoses including malignant neoplasm of the oropharynx, rheumatoid arthritis, hypotension, and convulsions, and who had a PEG tube and impaired cognition, was observed during medication administration. The resident's care plan included interventions for aspiration risk and PEG tube care, but did not address the method of medication administration, specifically the practice of crushing and mixing medications together. Physician orders specified that Primidone, Hydroxychloroquine sulfate, and Midodrine were to be administered via PEG tube, but there was no order to crush and mix these medications together (cocktailing). During observation, an RN prepared the resident's medications by crushing all three tablets together, mixing them with water, and administering the combined mixture through the PEG tube, followed by a water flush. The RN confirmed there was no order to mix the medications together and was unaware if the physician had reviewed potential side effects or interactions from administering the medications in this manner. The DON also verified that there was no order to mix the medications and that facility policy required each medication to be administered separately through the enteral tube. This failure to follow physician orders and facility policy resulted in a significant medication error for the resident.