Significant Medication Error: Missed Lorazepam Doses Result in Withdrawal Seizure
Penalty
Summary
A resident with a history of anxiety disorder and chronic lorazepam use was readmitted to the facility with an order for lorazepam 2 mg twice daily. Upon readmission, the medication was not available, and multiple nursing staff documented in the electronic medical record that the resident was waiting for pharmacy delivery. Despite these notes, the resident did not receive any doses of lorazepam for several days following readmission. During this period, the resident began to experience withdrawal symptoms, culminating in a seizure that required transfer to the hospital. Hospital records confirmed that the resident had not received lorazepam since returning to the facility, and both the resident and hospital staff noted the absence of the medication. The resident reported a long-term history of lorazepam use and stated that she had not received her medication due to it being unavailable at the facility. A review of the medication administration record confirmed that several scheduled doses of lorazepam were not administered, with some doses lacking any documentation. Facility leadership confirmed during interviews that the resident did not receive any lorazepam doses during the specified period, resulting in benzodiazepine withdrawal and a seizure event.