Significant Medication Error Due to Incorrect Transcription of Diuretic Order
Penalty
Summary
A medication error occurred when a resident with a history of heart failure, pulmonary hypertension, and chronic kidney disease was readmitted to the facility with an order for Metolazone 5 mg to be administered three times a week. The order was incorrectly transcribed by a registered nurse to be given three times daily, resulting in the resident receiving seven doses over three days instead of the intended two doses. The facility's policy required medications to be administered according to the prescriber's orders, but this was not followed in this instance. The resident's care plan identified a risk for dehydration related to diuretic medications, with interventions to administer medications as ordered. Progress notes indicated that after the medication error, the resident appeared fatigued and had a low blood pressure reading. Subsequently, the resident was found unresponsive on the floor with significant facial trauma and bleeding, and was transferred to an acute care hospital, where the resident later died. EMS documentation confirmed the resident was not breathing upon their arrival and required resuscitation efforts. Interviews with facility staff, including the nurse who transcribed the order, the DON, and a pharmacist, confirmed the error in transcription and administration of Metolazone. The pharmacist noted that the prescribed frequency was typical and that excessive dosing could lead to adverse effects such as dehydration, lethargy, and hypotension. The facility was unable to provide evidence that it ensured residents were free from significant medication errors, as required by policy.