Resident Received Double Dose of Synthroid Due to Medication Order Error
Penalty
Summary
A deficiency occurred when a resident received double doses of Synthroid (levothyroxine) due to a failure in medication order management. The resident's endocrinologist faxed a new order to increase Synthroid to 150 mcg, which was verbally verified by the in-house NP and transcribed by the assigned nurse onto the medication administration record (MAR). However, the previous order for Synthroid 137 mcg was not discontinued, resulting in the resident receiving both the old and new doses for four consecutive days. This medication error was identified during a review of the resident's medical records and confirmed by the Director of Nursing (DON), who stated that staff are expected to double-check medication orders and discontinue previous orders when new ones are received. The error led to the resident receiving double the intended dose of Synthroid, which was also associated with an abnormal lab value as noted in the complaint.