Failure to Prevent Significant Medication Errors in Blood Pressure Management
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of Midodrine, a medication used to treat hypotension. The resident, a male with diagnoses including End Stage Renal Disease, dependence on renal dialysis, Type 2 Diabetes, hypertensive heart and chronic kidney disease, atherosclerotic heart disease, and peripheral vascular disease, had physician orders for Midodrine with specific blood pressure parameters. However, there was a lack of clarity in the physician's order regarding the exact blood pressure parameters for holding the medication, with conflicting instructions noted in the order and medication administration record (MAR). Despite the order to hold Midodrine for a systolic blood pressure (SBP) greater than 120, the medication was administered eight times in May when the resident's SBP exceeded this threshold. Documentation showed that staff, including a medication aide, an RN, and an LVN, administered the medication outside of the ordered parameters, with blood pressures recorded as high as 167/82 at the time of administration. Interviews with staff revealed that some were aware of the intended use of Midodrine but did not consistently follow the ordered parameters, sometimes due to being rushed or misunderstanding the order. The resident was cognitively intact and reported feeling well, with no complaints of adverse effects at the time of interviews. Facility policy required staff to follow prescription instructions and resolve discrepancies before administering medications, but this was not adhered to in this case. The failure to clarify the order and to administer the medication as prescribed constituted a significant medication error for the resident.