Significant Medication Error Due to Pharmacy Labeling
Penalty
Summary
A medication error occurred when a resident, who was moderately cognitively impaired and required staff assistance for daily care, was administered the wrong medication for several days. The resident was supposed to receive rosuvastatin calcium, but due to a pharmacy labeling error, was instead given warfarin tablets. The error was discovered when a medication nurse identified a discrepancy in the medication card, which was labeled as rosuvastatin calcium but contained warfarin. The resident's clinical records showed that she had diagnoses including heart failure and was discharged from the facility after the incident. Following the administration of the incorrect medication, the resident's blood work revealed a critically elevated INR of 7.0, indicating a significant alteration in blood clotting time. The facility notified the physician and family, and the pharmacy was contacted regarding the labeling error. However, there was no documented evidence that the facility investigated whether other medication cards in the facility were also mislabeled by the pharmacy. The facility later ended its contract with the pharmacy due to this breach in service.