Significant Medication Error: Incorrect Oxycodone Dose Administered
Penalty
Summary
A significant medication error occurred when a resident with chronic obstructive pulmonary disease and a recent femur fracture was administered an incorrect dose of oxycodone. The resident had a physician's order for 2.5 mg (half tablet) of oxycodone every 8 hours as needed for pain, but on the morning in question, an LPN administered a full 5 mg tablet instead of the prescribed half dose. This error was confirmed by both the Medication Administration Record and an employee witness statement, which indicated the nurse forgot to split the tablet. Following the administration of the incorrect dose, the resident experienced a sudden change in mental status, including diaphoresis, a blank stare, and unresponsiveness. Medical staff responded by assessing the resident, obtaining new orders, and administering naloxone (Narcan) to reverse the opioid effects. The resident's condition improved within minutes after intervention. The Director of Nursing confirmed the medication error and noted that the resident's poor renal clearance contributed to the adverse response.