Pharmacist Failed to Identify and Report Adverse Drug Reactions and Allergy
Penalty
Summary
The consulting pharmacist failed to identify and notify the physician of potential adverse drug reactions (ADRs) related to the concurrent administration of opioids and benzodiazepines for a female resident with multiple complex diagnoses, including acute and chronic respiratory failure, paroxysmal atrial fibrillation, COPD, Alzheimer's disease, major depressive disorder, and atherosclerotic heart disease. The resident, who had a BIMS score of 2 indicating severely impaired cognition, was prescribed lorazepam (a benzodiazepine) as needed for anxiety and tramadol (an opioid) daily, despite a documented allergy to tramadol (hallucinations). The resident was frequently observed asleep throughout the survey period, with little documentation regarding her sleep patterns or quality of life. Record review showed no evidence that the pharmacist identified or communicated the risks of concurrent use of these CNS depressants, nor was there documentation that the physician was notified about the resident's tramadol allergy. Monthly Monitoring Reports and Gradual Dose Reductions did not address the concurrent use of opioids and benzodiazepines, and there was no documentation that drug-to-drug interactions or possible adverse reactions were considered. Interviews with nursing and pharmacy staff confirmed the lack of physician notification and insufficient documentation regarding the resident's medication regimen and its potential risks.