Significant Medication Error: Duplicate Dose of Mounjaro Administered
Penalty
Summary
Staff failed to prevent a significant medication error when a resident with morbid obesity and Type 2 diabetes mellitus received two doses of Mounjaro (tirzepatide) 12.5 mg within 24 hours, contrary to the physician's order for once-weekly administration. The error occurred when staff administered Mounjaro instead of the resident's scheduled Emgality injection for migraine prophylaxis. The medications were stored together in the same refrigerator and appeared similar, contributing to the confusion. The electronic medication administration record (MAR) continued to prompt for Mounjaro administration, which also contributed to the error. The nurse who administered the medication did not read the medication label carefully, leading to the administration of the wrong drug. Following the error, the nurse notified the resident, nurse practitioner, guardian, and charge nurse, and Poison Control was contacted. The nurse practitioner ordered enhanced monitoring, including holding the resident's oral antidiabetic medications and increasing blood glucose checks. However, documentation showed that staff only continued routine blood sugar checks and did not increase monitoring or document reassessment for side effects or symptoms beyond the resident's baseline schedule. There was no nursing narrative assessing for symptoms or evidence of monitoring for adverse effects as recommended.