Medication Order Transcription Error for Gabapentin
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident diagnosed with polyneuropathy. Upon admission, the resident had a hospital discharge order for Gabapentin 100 mg to be administered every 8 hours, which equates to three times daily. However, the active physician orders at the facility listed Gabapentin 100 mg to be given only twice daily, scheduled at 8:00 AM and 4:00 PM. This discrepancy was not identified or corrected by facility staff responsible for entering and verifying medication orders. Interviews with the nurse practitioner, unit manager, and director of nursing confirmed that the medication should have been administered three times daily as per the hospital discharge paperwork. All interviewed staff acknowledged that the order was incorrectly transcribed and that this constituted a medication error, as the facility's policy requires medication orders to be evaluated for correct dose, route, duration, and frequency in accordance with clinical guidelines.