Significant Medication Error Due to Incorrect Order Entry
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease and dementia was prescribed ropinrole HCl 0.5 mg three times daily, but the order was incorrectly entered into the electronic medical record as 5 mg four times daily. As a result, the resident received significantly higher doses of the medication over multiple administrations. The error was not detected by the pharmacy or management, and the medication was administered as entered in the system. Following the administration of the incorrect dosage, the resident experienced adverse symptoms including hypertension, headache, hallucinations, increased anxiety, and dizziness. The error was confirmed through interviews with the Director of Nursing and the LPN responsible for entering the order, both of whom acknowledged the mistake and the lack of system alerts or oversight that could have prevented the error.