Consultant Pharmacist Failed to Identify and Report Medication Transcription Errors
Penalty
Summary
A deficiency occurred when the Consultant Pharmacist failed to identify and report medication transcription errors for a resident admitted with dementia and benign prostatic hyperplasia (BPH). Upon admission, the hospital discharge summary listed Finasteride 5 mg daily and Melatonin 30 mg at bedtime, but the facility's physician orders transcribed these as Finasteride 5 mg twice daily and Melatonin 10 mg at bedtime. There was no documentation of a verbal order authorizing these changes. The resident's Medication Administration Record (MAR) reflected administration of the incorrect dosages as per the facility's orders. During the monthly medication regimen review, the Consultant Pharmacist did not detect or report these discrepancies, stating during an interview that she had not noticed any dose errors and would have notified the Director of Nursing (DON) if she had. The DON confirmed that no notification was received regarding a discrepancy for this resident. The Medical Director, upon review, noted the high dose of Melatonin and expected staff and the Consultant Pharmacist to cross-check admission medication orders for accuracy. The Administrator also indicated that the Consultant Pharmacist would typically communicate any discrepancies, which did not occur in this case.