Medication Reconciliation Failure Leads to Administration of Discontinued Drug
Penalty
Summary
A significant medication error occurred when a resident, who had recently returned from a hospital stay, was administered five doses of Valacyclovir 1000mg after the hospital discharge summary had clearly stated to discontinue the medication. The resident had a history of acute and subacute infective endocarditis and required hemodialysis. Upon readmission, an agency nurse was responsible for entering the resident's medications into the electronic medical record but failed to discontinue Valacyclovir as ordered in the hospital discharge instructions. The medication error was not immediately identified, and the resident received multiple doses of the discontinued medication over two days. The error was discovered only after the resident exhibited confusion, slurred speech, and inability to follow commands, as reported by a family member and confirmed by a bilingual LVN. The resident was subsequently assessed by a nurse practitioner and transferred back to the hospital, where the diagnosis of metabolic encephalopathy due to Valacyclovir toxicity was made. Interviews revealed that the agency nurse responsible for the error was unfamiliar with the electronic medical record system and did not seek assistance or clarification. The facility's medication reconciliation policy required review of discharge medication profiles with readmission orders, but this process was not properly followed, resulting in the administration of a discontinued medication and subsequent harm to the resident.