Significant Medication Error: IV Antibiotic Administered at Incorrect Rate
Penalty
Summary
A deficiency occurred when a nurse administered an intravenous antibiotic, meropenem, to a resident at an incorrect infusion rate. The resident, who had a history of osteomyelitis in the left ankle, chronic kidney disease stage 4, and diabetes mellitus, was prescribed 1 gram of meropenem to be infused intravenously every 12 hours over 60 minutes. The pharmacy label on the medication also specified that the 100ml dose should be infused over 60 minutes. During medication administration, the nurse set the intravenous flow regulator to 200ml per hour, resulting in the medication being infused over 30 minutes instead of the prescribed 60 minutes. The nurse stated that the physician's order did not specify a flow rate, so she used her previous practice of setting the rate at 200ml per hour and set an alarm to return in 45 minutes, expecting the infusion to be completed. The nurse did not follow the pharmacy label instructions, which clearly indicated the correct infusion rate. Facility policy required nursing staff to review the physician's order, including the rate, and to administer medications according to the prescribed rate. The Director of Nursing confirmed that the flow regulator should have been set to the pharmacy's recommended rate of 100ml per hour. The failure to administer the medication at the correct rate constituted a significant medication error, as it did not comply with the prescribed method of administration.