Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in three medication errors out of 27 opportunities observed, which equated to an 11.11% medication error rate. During a medication pass, a registered nurse prepared and administered medications to a resident with multiple diagnoses, including schizoaffective disorder, COPD, major depressive disorder, and syndrome of inappropriate secretion of anti-diuretic hormone. The nurse prepared only one 10 mg tablet of Fluphenazine instead of the ordered two tablets, omitted Bumetanide (Bumex) and Aspirin from the initial medication cup, and later provided an enteric coated Aspirin instead of the prescribed chewable tablet. The errors were identified when the resident questioned the absence of Bumex and Aspirin in the medication cup, prompting the nurse to review the orders and subsequently provide the missing medications. The nurse acknowledged the errors during an interview, confirming the incorrect dosage and formulation of medications administered. These actions resulted in a medication error rate above the acceptable threshold, affecting one resident reviewed for medication administration.