Significant Medication Errors Involving Insulin Administration, Antibiotic Dosing, and Expired Inhaler Use
Penalty
Summary
Three residents experienced significant medication errors due to failures in medication administration and adherence to physician orders and manufacturer guidelines. One resident with type 2 diabetes and chronic kidney disease received insulin injections at the same anatomical sites repeatedly, rather than rotating injection sites as required by standard of care and facility policy. This practice was confirmed through review of administration records and interviews with nursing staff, who acknowledged that site rotation was not performed as required. Another resident with chronic obstructive pulmonary disease (COPD) and a recent diagnosis of bronchitis was prescribed a course of azithromycin. The physician's order specified a dosing schedule that was not correctly transcribed into the Medication Administration Record (MAR), resulting in the omission of a scheduled dose. The Assistant Director of Nursing admitted to the transcription error, which led to the antibiotic dose being administered late, contrary to the physician's instructions. A third resident, also with COPD, was administered nine doses of an expired fluticasone and salmeterol inhalation powder Diskus. The inhaler had been opened and stored beyond the manufacturer-recommended one-month period, but was not removed from the medication cart as required by facility policy. Multiple nurses administered the expired medication, and staff interviews confirmed awareness of the expiration guidelines and the error in not removing the medication from use.