Mismatch Between Emergency Kit Medication List and Contents
Penalty
Summary
The facility failed to ensure that the medication listed on the oral medications' Emergency kit (Ekit) index matched the medication actually present in the Ekit. During an observation and interview with a registered nurse, it was found that slot number 25 in the Ekit, which was supposed to contain potassium chloride 20 mEq, instead contained four tablets of nitrofurantoin 50 mg. The registered nurse stated that the pharmacist is responsible for verifying Ekit contents upon delivery, and that discrepancies could lead to medication errors or delays. The dispensing pharmacist confirmed that the on-duty pharmacist should verify Ekit contents against the list and that any discrepancies should result in the Ekit being returned to the pharmacy. Review of facility policy indicated that the consultant pharmacist is required to monitor and inventory emergency kits at least every 30 days for completeness and expiration dating.