Significant Medication Error: IV Vancomycin Administered at Incorrect Rate
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) intentionally administered an intravenous antibiotic, Vancomycin, to a resident at a rate of 250 ml/hr instead of the ordered 150 ml/hr. The pharmacy label clearly indicated the correct rate, but the RN did not follow the order and did not use a medication pump as required. The nurse was aware of the correct rate but chose to administer the medication more rapidly due to the resident's combative behavior and the unavailability of a pump. The nurse did not notify nursing management of the deviation from the order and did not perform an immediate assessment of the resident after the error. The resident involved had multiple medical conditions, including COPD, muscle weakness, depression, a history of amputation, and an open wound, and was noted to have severely impaired cognition. At the time of the incident, the resident was confused, combative, and not interviewable. The Vancomycin was administered using dial-a-flow tubing, which the nurse had not previously used and for which she had not received training. The IV bag was missing a pharmacy label at the time of administration, and the nurse later retrieved a new label confirming the correct infusion rate. The nurse admitted to not having received training on significant medication errors, IV medication administration, or the use of dial-a-flow tubing prior to this incident. Facility policy required medications to be administered as prescribed, with staff verifying the label and following the seven rights of medication administration. The nurse did not follow these procedures, and the error was not immediately reported or managed according to policy. Interviews with facility leadership and pharmacy staff confirmed that the medication was not administered as ordered and that the nurse had not been properly oriented or assessed for competency in IV medication administration.