Significant Medication Error Due to Transcription and Administration Failures
Penalty
Summary
A significant medication error occurred when a resident was administered 40 mg of methadone, which was 16 times the prescribed dose of 2.5 mg. The error originated from a handwritten order by a hospice RN, which incorrectly indicated the volume to be administered and did not comply with Board of Pharmacy requirements for prescription clarity. The order was then transcribed into the electronic health record as 4 mL instead of the correct 0.25 mL, due to misinterpretation of the handwriting and lack of a leading zero. The medication bottle from the pharmacy had a different instruction, indicating a dose of 0.5 mL (5 mg), further adding to the confusion. The resident, who had no cognitive impairment but was dependent on staff for activities of daily living and had diagnoses including a femur fracture and COPD, received the incorrect dose via g-tube. The nurse administering the medication noticed the discrepancy between the MAR and the medication bottle but proceeded to give the dose listed in the MAR, believing it to be the most current order. The nurse did not seek clarification despite the mismatch. The double-check process for new orders was not completed, as the order sheet was left next to the computer without verification by another nurse, contrary to facility protocol. Following administration, the resident exhibited symptoms of opioid overdose, including lethargy, low respiratory rate, low oxygen saturation, and unresponsiveness. Narcan was administered at the facility, and the resident was transferred to the hospital, where they required intensive care and a continuous Narcan infusion due to persistent symptoms of methadone overdose. Interviews with staff confirmed that the medication should not have been administered when discrepancies were noted, and that the double-check process was not followed due to a busy shift.
Removal Plan
- Suspend the nurse who administered the incorrect dose and educate all nurses.
- Educate the nurse manager on clarification of any orders that are scribbled, dose increase that is too high or the handwriting is not legible.
- Educate the nurse who administered the incorrect dose that whenever a discrepancy on the MAR and the medication bottle or bubble pack, the order must be clarified, and the medication should not be administered.
- Educate hospice agency nurse related to transcription error and conflicting orders from the hospice doctor and the nurse.
- Revise hospice agency procedure for ordering medications.
- Audit all hospice residents' provider orders and correct any errors. Audit all new orders.
- Educate all licensed nursing staff/contracted agency nurses on the rights of medication administration, transcription of medications, processing of medications, narcotic administration and side effects, and what to do when a med error occurs. Ensure all staff receive education before their next shift.
- Develop a system to ensure appropriate transcription and order double check. Nurses confirm knowledge of the new transcription procedure into the electronic health record system. Add triple check of all new orders to the night shift nurse duty list.
- Review policies and procedures related to medication administration, transcription, and transcription errors.
- Review hospice contracts for medication management.