Medication Transcription Errors Lead to Resident Harm and Hospitalization
Penalty
Summary
A medication transcription error occurred when a resident with chronic kidney disease, renal insufficiency, and other comorbidities was prescribed Bumex 2 mg by mouth daily for three days. The order was incorrectly transcribed as Bumex 2 mg by mouth three times daily with no stop date, resulting in the resident receiving 36 doses over 12 days instead of the intended 3 doses. This error led to an 18.8-pound weight loss, critical laboratory abnormalities, vomiting, and ultimately hospitalization for acute kidney injury and infection. The error was not identified by staff until after the resident exhibited significant symptoms and laboratory results indicated dehydration and kidney dysfunction. The facility's process for transcribing and verifying medication orders was inadequate. The health unit coordinator (HUC) responsible for transcribing the order was new to the position and lacked a medical background, including knowledge of common medical abbreviations such as QD and TID. The nurse manager, who was supposed to perform a second check of the transcription, failed to do so, allowing the error to persist. Additionally, staff did not recognize the inappropriateness of administering a diuretic in the evening or the resident's significant weight loss, and a scheduled weekly weight was missed during the period of the error. Further review revealed two additional medication transcription errors involving another resident, where antipsychotic and bladder medications were administered at incorrect dosages due to similar transcription mistakes. In these cases, the errors were identified by the facility pharmacy and corrected, but no audits of other recently transcribed orders were conducted at that time. The cumulative failures in order transcription, verification, and monitoring led to significant harm for the affected resident and demonstrated systemic issues in medication management within the facility.
Removal Plan
- Determine the root cause for transcription/medication errors and put in place additional safeguards.
- Review and revise policy and procedures as needed.
- Educate staff on new procedures.