Failure to Prevent Unnecessary Drug Therapy and Address Drug Interactions
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary medications, specifically related to duplicate drug therapy and unaddressed drug-to-drug interactions. The resident, who had multiple diagnoses including major depressive disorder, generalized anxiety disorder, and insomnia, was admitted with several medication orders, including escitalopram, fluoxetine, and quetiapine. Upon admission, an incorrect dosage of quetiapine was administered twice before being corrected. Additionally, a new order for buspirone was entered, which triggered pharmacy alerts for potential additive serotonergic effects and risk of serotonin syndrome due to interactions with other prescribed medications. There was no documentation that the physician or pharmacy had been consulted regarding these alerts. Interviews with facility staff revealed that nurses are expected to notify physicians and consult with pharmacists when pharmacy alerts for drug interactions occur. However, in this case, the responsible staff did not communicate the pharmacy warnings to the prescribing practitioner, and the practitioner was unaware of the interactions. The DON confirmed that it is the facility's expectation for nurses to notify physicians of such alerts, but this protocol was not followed, resulting in the resident receiving unnecessary and potentially harmful medications.