Significant Medication Error: Unprescribed Oral Medication Administered via Wrong Route
Penalty
Summary
A significant medication error occurred when a certified medication assistant (CMA) administered Amiodarone and Vitamin B12 to a male resident who was not prescribed these medications. The resident had a history of a left middle cerebral artery stroke, dysphagia requiring a PEG tube for all nutrition and medication administration, and moderately impaired cognition. According to the care plan and physician's orders, the resident was not safe for oral intake and all medications were to be given via the PEG tube. Despite these orders, the CMA gave the resident oral pills, which the resident swallowed after being told by the staff that he needed to take them, even though he expressed reluctance. The error was discovered after the resident reported the incident to another nurse, who then escalated the issue to the Director of Nursing (DON) and the nurse practitioner (NP). Interviews with staff confirmed that the medications given were not prescribed for the resident, and that Amiodarone, in particular, is a high-risk cardiac medication that should only be administered when specifically ordered. The facility's medication administration policy requires staff to verify physician orders, the medication administration record (MAR), and the resident's identity before administering any medication. In this case, the CMA failed to follow these protocols, resulting in the administration of unprescribed medications by the wrong route. Staff interviews further revealed that all licensed and certified staff are responsible for verifying medication orders and following the seven rights of medication administration. The DON and other staff confirmed that the CMA did not check the MAR or the care plan before giving the medications, and that the resident was not prescribed Amiodarone or Vitamin B12 at the time. The incident was attributed to the CMA confusing residents during medication pass and not adhering to established procedures for medication verification and administration.