Medication Dispensing and Administration Error Leads to Resident Death
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services to meet the needs of a resident, resulting in a significant medication error. The pharmacy dispensed conventional amphotericin B instead of the prescribed amphotericin B liposomal (AmBisome), which are different formulations with distinct dosing requirements. The physician's order specified amphotericin B liposomal 350 mg in 250 ml D5W to be administered over two hours, but the pharmacy delivered seven vials of amphotericin B 50 mg each, along with a 250 ml bag of D5W. The medication delivered did not match the physician's order, and the packaging included a warning that the maximum daily dose should not exceed 1.5 mg/kg, which was not observed. The nurse (RN) who administered the medication did not recognize the difference between the two formulations and prepared the entire 350 mg dose of amphotericin B in 250 ml D5W, administering it at a rate of 125 ml/hr. This resulted in the resident receiving over three times the maximum recommended dose of amphotericin B, at a concentration and rate higher than recommended by the manufacturer. The nurse did not double-check the medication label against the physician's order, nor did he research the medication prior to administration, despite the packaging containing a clear warning about dosing limits. The nurse also stated this was the first time he had administered amphotericin B and did not notice the discrepancy in medication names. The resident, who had a history of mucormycosis, respiratory failure, a tracheostomy, and was ventilator dependent, experienced a rapid deterioration in condition shortly after the infusion began and was found without a pulse a few hours later. The pharmacy's Chief Compliance Officer confirmed the error in dispensing and noted that the medication was not labeled with a high alert warning as required for high-risk medications. The Director of Nursing acknowledged that the nurse did not follow the facility's policy for verifying the right medication and dose prior to administration.