Medication Error Rate Exceeds 5% Due to Incorrect Administration and Product Substitution
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with three medication errors identified out of 28 opportunities, resulting in a 10.71% error rate. Two errors involved one resident who did not receive Glimepiride 4 mg before breakfast as ordered by the physician and was also administered the incorrect eye drop medication. Specifically, the resident received artificial tears lubricant eye drops instead of the prescribed Systane Ophthalmic Solution, and the Glimepiride was not given prior to breakfast as directed in the physician's order. These errors were observed during medication administration and confirmed through review of the resident's medical records and physician orders. A third medication error involved another resident who was administered Visine dry eye relief lubricant instead of the prescribed Artificial Tears Solution 1.4% (Polyvinyl Alcohol). The error was observed during the medication pass and later verified by comparing the administered medication to the physician's order. Interviews with nursing staff confirmed that medications are expected to be administered according to physician orders, including timing and specific products, but these expectations were not met in the observed instances.