Failure to Ensure RN Competency in IV Medication Preparation and Administration
Penalty
Summary
The facility failed to ensure that registered nurses (RNs) were properly trained and competent in the preparation and administration of intravenous (IV) medications, specifically regarding the reconstitution of IV medications and the administration of amphotericin B. The Nursing Skills Competency Checklist for RNs did not include reconstitution of IV medications as a required competency, and RN 3 had not received training or been signed off as competent in this area. Additionally, RN 3 administered amphotericin B for the first time without researching the medication or recognizing the difference between amphotericin B and amphotericin B liposomal (AmBisome), as ordered by the physician. A resident with a history of mucormycosis, respiratory failure, tracheostomy, and ventilator dependence was ordered to receive amphotericin B liposomal (AmBisome) 350 mg in dextrose 5% 250 ml IV. The pharmacy delivered amphotericin B 50 mg vials and dextrose 5% solution to RN 3, who then administered the medication without verifying the specific product or dosage warnings. The packaging of the amphotericin B delivered did not match the physician's order, and RN 3 did not double-check the medication or consult additional resources prior to administration. This resulted in a medication error that contributed to the resident's death. Interviews with facility staff revealed that RNs had not been observed or signed off for competency in reconstituting IV medications, and the Director of Nursing (DON) expected nurses to look up unfamiliar medications but did not ensure this was done. The Clinical Consultant confirmed that RNs should have been trained and signed off for competency before reconstituting IV medications, but this had not occurred. The lack of proper training and competency assessment for IV medication preparation and administration led directly to the medication error and adverse outcome.