Failure to Prevent Significant Medication Errors Due to Missed IV Antibiotic Doses
Penalty
Summary
A resident with a history of intraspinal abscess, infection following a procedure, candidiasis, COPD, asthma, depression, and muscle weakness was admitted and receiving IV antibiotic therapy via a PICC line for sepsis and infection. The resident's care plan included administration of IV antibiotics and fluids as ordered, with specific interventions for PICC line maintenance and monitoring for adverse reactions. Physician orders included Micafungin Sodium-NaCl IV solution to be given every 24 hours and Cefazolin Sodium injection every eight hours for a specified duration. Review of the Medication Administration Record (MAR) revealed multiple missed doses of both Cefazolin and Micafungin on several dates. The missed doses were marked as not given, and interviews with nursing staff indicated that when the PICC line was not usable or had come out, the antibiotics were not administered until the line was reinserted. The facility's policy required nurses to notify the physician if medication would be given late or to obtain an alternative order, but this protocol was not followed. The DON confirmed that the expectation was for nurses to contact the physician for an alternative route or order when the PICC line was not available.