Medication Error Rate Exceeds Acceptable Threshold Due to Nurse Oversight
Penalty
Summary
A medication error rate of 7.69% was identified during a medication pass observation, exceeding the acceptable threshold of less than 5%. Specifically, two medication errors occurred out of 26 opportunities for one resident with hypertension. The first error involved a nurse administering carvedilol, a medication with specific parameters requiring blood pressure and heart rate assessment prior to administration, without performing these assessments. The nurse did not notice the parameters attached to the order and administered the medication without obtaining the necessary vital signs. The second error occurred when the same nurse failed to administer folic acid as ordered for the resident. The nurse stated she overlooked the folic acid order. Interviews with the nurse, the nurse practitioner, and the DON confirmed awareness of these errors. The DON noted that the electronic system did not enforce the required parameters for carvedilol, which contributed to the error, but also stated that the nurse should have checked each medication order more carefully.