Significant Medication Errors in Antibiotic and Insulin Administration
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration and order entry. One resident, admitted with multiple complex diagnoses including pseudomonas infection and a history of urogenital implants, was prescribed cefepime as a continuous 24-hour IV infusion. However, upon admission, the antibiotic order was incorrectly entered as a twice-daily short infusion rather than a continuous infusion. This error persisted for several days, with the medication being administered incorrectly each shift. The discrepancy was eventually identified after the resident's infectious disease physician and family raised concerns, revealing that the facility had not followed the hospital's discharge prescription for continuous infusion. Another resident with a history of diabetes mellitus and other chronic conditions was prescribed sliding scale insulin to be administered subcutaneously before meals. Review of the medication administration record for this resident showed that insulin was administered late on 22 occasions within a single month. The scheduled times for insulin administration were not adhered to, with doses being given significantly after the prescribed times. Staff interviews indicated that some nurses believed they had a window of time for administration, and some attributed the discrepancies to delayed documentation rather than actual late administration. The facility's policies required that medications be administered and documented in real time, and that orders be accurately entered and verified by nursing staff. Despite these policies, the errors occurred due to incorrect order entry, lack of proper verification, and failure to document medication administration at the time it was given. These actions and inactions led to significant medication errors affecting two residents.