Medication Error Rate Exceeds 5% Due to Improper Lidocaine Patch Administration
Penalty
Summary
Nursing staff failed to ensure the medication error rate remained below 5% when a 4% lidocaine patch was administered to a resident's knees on two separate occasions, rather than to the lower back as prescribed by the physician. Specifically, a registered nurse applied the patch to the resident's left knee during one medication pass, and a licensed vocational nurse applied the patch to the right knee during another medication pass. The physician's order clearly indicated the patch was to be applied to the lower back once daily for pain management. The nursing supervisor confirmed that any change in the application site required physician approval and a corresponding order change. These actions resulted in two medication errors out of 27 observed opportunities, leading to a medication error rate of 7.41%. The resident involved had a medical history including heart failure, osteoarthritis, and a current pathological vertebral fracture, and was admitted with these diagnoses. The errors were identified through observation, interview, and record review during the survey process.