Medication Error Rate Exceeds Threshold Due to Improper Administration
Penalty
Summary
During a medication administration observation, an LPN prepared and administered seven medications to a resident, including potassium chloride extended release and duloxetine hydrochloride delayed release. The LPN opened the duloxetine capsule and placed its contents in a medication cup, then crushed the potassium chloride tablet along with other medications before mixing them with applesauce and administering them to the resident. Review of the resident's physician orders indicated that medications could be crushed unless contraindicated, but specifically ordered duloxetine as a delayed release capsule and potassium chloride as an extended release tablet, both of which should not be altered. Manufacturer guidelines for both duloxetine delayed release and potassium chloride extended release specify that these medications should be swallowed whole and not crushed, chewed, or opened. The facility's own policy also states that long-acting, extended release, or enteric coated dosage forms should generally not be crushed, and alternatives should be sought. The medication error rate during this observation was calculated at 7.69%, exceeding the acceptable threshold of 5%.