Medication Transcription Error on Admission Leads to Multiple Medication Errors
Penalty
Summary
The facility failed to ensure that medications were transcribed correctly upon admission for a resident, resulting in significant medication errors. Upon admission, a staff member transcribed medication orders for the resident, but the orders entered into the resident's record were actually those intended for another resident. This error was not identified because the required second nurse check, as outlined in facility policy, was not completed. As a result, the resident received multiple medications that were not prescribed for him over several days. The resident's family member noticed that a staff member attempted to administer unfamiliar medications and raised concerns with the staff. Despite this, the resident continued to receive incorrect medications for several days. The clinical record review confirmed that 11 medications not ordered by the transferring hospital were administered in error, with a total of 23 incorrect doses given over four days. The medications included drugs for Alzheimer's disease, overactive bladder, anxiety, high blood pressure, diarrhea, stomach acid, potassium supplementation, pain, depression, nausea, and constipation. The facility's own policies required that all new admission orders be double-checked by a second nurse and that the five rights of medication administration be followed. However, these procedures were not followed in this case, leading to the administration of multiple incorrect medications. The error was only discovered after several days when a review of the records was conducted, confirming that the resident had received medications intended for another individual.