Medication Transcription and Administration Error Resulting in Overdose
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure that medication orders were accurately transcribed and administered according to professional standards. A resident with a history of rectal and lung cancer and atrial fibrillation was admitted and later readmitted to the facility. Upon the resident's discharge to the hospital, an order for apixaban 5 mg twice daily was not discontinued, and the medication remained accessible in the medication cart. When the resident was readmitted, new orders for apixaban 2.5 mg twice daily were transcribed, but the previous 5 mg order was still active on the medication administration record (MAR). On the day of readmission, an agency LPN administered both the 5 mg and 2.5 mg doses of apixaban, resulting in a total dose of 7.5 mg, which exceeded the prescribed amount and constituted a medication error. The facility's medication error report confirmed that the previous order had not been discontinued and that the medication was still available in the cart. Additionally, the report noted that no employee witness statements were obtained at the time of the incident. The Director of Nursing acknowledged that professional nursing standards were not followed, leading to the medication error.