Crushing of Extended-Release Medication Results in Significant Medication Error
Penalty
Summary
A certified medication aide crushed and administered an extended-release (ER) metoprolol tablet to a resident by mixing it with applesauce, despite the medication label indicating 'Do not crush.' The aide proceeded with this action even after being questioned about the appropriateness of crushing the ER medication, stating she would consult the nurse later. Review of the medication records revealed that the current physician order was not for ER metoprolol, but the medication card still reflected the ER formulation, leading to confusion. The administrative nurse confirmed that the medication administration did not align with the current physician order and that the pharmacy had not been notified of the order change in a timely manner, resulting in an incorrect Medication Administration Record (MAR). The facility's policy requires medications to be administered according to prescriber orders and verified for correct method of administration prior to delivery.