Medication Error Due to Incorrect Transcription of Antibiotic Order
Penalty
Summary
A medication error occurred when a resident, who was readmitted to the facility following hospitalization for sepsis and ureteral stent placement, did not receive a prescribed oral antibiotic (Sulfamethoxazole-Trimethoprim) as ordered. The resident's physician had ordered the antibiotic to be administered twice daily for seven days, starting immediately upon the resident's return to the facility. However, the order was incorrectly transcribed by an LPN, who entered an incorrect start date, resulting in a six-day delay in the administration of the antibiotic. The resident's medical records and nurse's notes confirmed that the antibiotic was not given between the dates of readmission and the corrected start date. The error was discovered after a VA case manager noticed a new order for the antibiotic and sought clarification, leading to the realization that the medication had not been started as intended. The DON verified that the staff nurse had entered the wrong date, which caused the delay in treatment. Throughout the period when the antibiotic was not administered, documentation indicated that the resident exhibited no fever, pain, or urinary complaints, and the urinary catheter remained intact with clear, yellow urine. The resident was alert, oriented, and denied any issues related to the catheter or signs of neglect during interviews. The error was attributed to the incorrect transcription of the medication order upon readmission, and the responsible staff member could not be reached for further comment during the investigation.