Significant Medication Error Due to Failure to Follow Medication Administration Protocols
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN) administered an incorrect dose and form of Methadone to a resident. The LPN gave 105 mg of liquid Methadone, which was prescribed for another resident for opioid dependence, instead of the 10 mg Methadone tablet ordered for pain management. The LPN did not verify the physician's order prior to administration and failed to follow the facility's medication administration policy, specifically neglecting to ensure the six rights of medication administration. The error was not recognized by the LPN at the time of administration, and the nurse only became aware of the mistake after being contacted by another staff member regarding a missing bottle of Methadone. The affected resident had a history of unspecified pain, hypertension, and depression, with a moderately impaired cognitive status as indicated by a Brief Interview of Mental Status (BIMS) score of 11 out of 15. After receiving the incorrect medication, the resident was initially found alert but later became lethargic and semi-responsive. The resident required emergency intervention, including administration of Narcan, oxygen therapy, and transfer to a hospital, where they were admitted with a diagnosis of Methadone overdose. Interviews with staff and review of facility documentation confirmed that the LPN did not follow established protocols for medication administration, including verifying the correct medication, dose, and form against the medication administration record (MAR) and physician's order. The Director of Nursing (DON) and the LPN both acknowledged that the facility's policy was not followed during the incident. The failure to adhere to these protocols resulted in a significant medication error that required emergency medical intervention.