Failure to Prevent Significant Medication Error Related to Blood Pressure Parameters
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension, heart failure, and orthostatic hypotension was administered Coreg (carvedilol) despite physician orders to hold the medication if the systolic blood pressure was less than 150 mmHg. The resident's blood pressure readings frequently fell below this threshold, yet Coreg was administered on numerous occasions as documented in the Medication Administration Records (MAR) for July, August, and September. The error was identified through record review, interviews with nursing staff, pharmacy consultant, nurse practitioner, and cardiologist, and was corroborated by therapy notes documenting episodes of dizziness and low blood pressure during therapy sessions. The resident's care plan included interventions to administer medications as ordered, assess for effectiveness, and report abnormalities to the physician. Despite these interventions, the MAR showed that Coreg was given when the resident's systolic blood pressure was below the ordered parameter on multiple dates. Interviews with nursing staff and medication aides revealed a lack of awareness or understanding of the hold parameters in the physician's order, with some staff admitting they did not read the full order or did not realize the medication should have been held. The Director of Nursing noted that the electronic MAR required scrolling to see the full order, which may have contributed to the oversight. Pharmacy consultant reviews also identified the error and documented that Coreg was administered contrary to the hold parameters, but there was no evidence that these recommendations were addressed by medical providers or nursing staff. The nurse practitioner and cardiologist were not aware that the medication had been administered outside of the prescribed parameters. The resident experienced symptoms consistent with orthostatic hypotension, including dizziness and low blood pressure during therapy, which were documented in therapy and nursing notes.