Failure to Administer Prescribed HIV Medication Due to Transcription Error
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of HIV received the physician-prescribed antiretroviral medication, Biktarvy, upon admission. Instead, the admitting nurse transcribed the order incorrectly, listing only one component of the medication, tenofovir alafenamide, rather than the full combination therapy required for effective HIV treatment. There was no documentation or recall as to why the order was changed, and neither the facility pharmacist nor the medical director reviewed or corrected the order prior to its implementation. As a result of this transcription error, the resident received only tenofovir alafenamide for several months, rather than the complete Biktarvy regimen. When the order for tenofovir expired, it was not renewed, and the resident subsequently received no HIV medication for a period of time. Throughout this period, the facility's nursing staff, pharmacist, and medical director failed to identify or address the omission, despite regular medication reviews and the resident's ongoing need for antiretroviral therapy as documented in the care plan and physician orders. The deficiency was discovered when the resident was sent to a hospital for routine HIV viral load testing, which revealed a significantly elevated viral load, indicating a lack of effective HIV treatment. The hospital physician noted that the resident's medication list from the facility did not include Biktarvy, and the resident was subsequently restarted on the correct medication. Interviews with facility staff confirmed that the resident was cooperative with care and did not refuse medications, and that the error was not identified until the hospital visit. The facility's failure to administer the prescribed medication as ordered resulted in a significant medication error and actual harm to the resident.
Removal Plan
- Resident #1's medication list was printed and reviewed with the facility physician for accuracy.
- The hospital's infectious disease office was contacted regarding follow-up appointment recommendations for lab monitoring.
- The DON or designee will prioritize reviewing current residents who are receiving clinically significant medications such as insulin, anticoagulants, cancer agents, antivirals, and medications for multiple sclerosis or Parkinson's, focusing on order accuracy.
- The DON/designee will review all remaining residents.
- The DON or designee reviewed all resident orders with a discontinuation date using the order listing report to ensure accuracy.
- Facility Medication policy was reviewed by the NHA, the DON, and the medical director.
- New admission orders will be reviewed against the discharge orders to ensure transcription accuracy. Any discrepancies identified will be clarified with the attending physician.
- The primary physician will review new admission orders in conjunction with the history and physicals to ensure accuracy.
- Consultant pharmacists will complete a review of new admissions for clinically significant risk. This review will include assessment of high-risk medications, potential interactions, contraindications, missing indications, and duplicate therapies. Any concerns identified will be communicated to the facility.
- The LPN who may not have transcribed the original order correctly was re-educated via phone by the assistant director of nursing (ADON). Education included the facility's policy regarding medication administration and reconciliation guidelines of noting who medications were verified with and any changes made during reconciliation.
- The staff development coordinator (SDC) or designee re-educated all licensed nurses on the facility's medication administration and reconciliation policy. Education included documenting who was verified for each medication, noting any changes made during reconciliation, completing a two-nurse verification of order accuracy, and clarifying when a long-term medication has a stop date.
- Any nurse who has not yet received the education will not work the floor until training is completed.
- Licensed nurses who have not worked have been terminated.
- Licensed nurses on a leave of absence will be educated upon their return and prior to working on the floor.
- Licensed nurses were unable to be reached by the SDC or designee and will not be scheduled to work until the required education is completed.
- The SDC/designee will educate agency licensed nurses on the facility's policy regarding medication administration and reconciliation guidelines. Education was uploaded to the agency portal.
- The agency platform requires the agency nurse to complete training before they can confirm the shift.
- The regional director of clinical services notified the pharmacy account representative of the error. A meeting has been scheduled with the pharmacy to review the error in detail and establish an ongoing plan for medication monitoring.