Significant Medication Error Due to Overlapping Furosemide Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses including chronic obstructive pulmonary disease, dysphagia, orthostatic hypertension, and chronic heart failure received an incorrect dosage of furosemide due to overlapping medication orders. The resident was admitted with intact cognition and required self-care assistance. Physician orders indicated that three 20 mg furosemide tablets were to be given once daily, which was later discontinued, and a new order for one 80 mg furosemide tablet once daily was initiated. However, both the discontinued and new orders were administered simultaneously on two consecutive days, resulting in the resident receiving a total of 140 mg of furosemide per day instead of the intended 80 mg. The error was confirmed through medical record review, staff interview, and policy review. The medical director verified that the previous order should have been discontinued when the new order was started, and that the resident received additional doses of the medication on the specified days. Facility policy required medications to be administered according to physician orders, but this was not followed, resulting in a significant medication error for the resident.