Medication Error: Excess IV Fluid Administration Due to Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure, chronic obstructive pulmonary disease, and morbid obesity was administered approximately 900 ml of Sodium Chloride 0.9% intravenously, instead of the prescribed one-time dose of 500 ml. The order specified that the infusion should be run at 75 ml/hour and reassessed at both 250 ml and 500 ml. The facility did not have a 500 ml IV bag available and used a 1000 ml bag, with a mark made at the 500 ml level to indicate where to stop the infusion. However, the infusion was not stopped at the correct volume, resulting in the resident receiving nearly double the ordered amount. The error was precipitated by a breakdown in communication and handoff procedures between nursing staff. The nurse who hung the IV bag reported the order and treatment plan to another nurse, who was assigned to a different hall and did not directly communicate with the nurse responsible for the resident. The oncoming nurse did not receive a verbal or written report about the IV order and did not check the resident's IV during her shift. Multiple staff interviews confirmed that the order was not properly communicated, and the nurse responsible for the resident did not review new orders or verify the IV status. As a result, the infusion continued beyond the prescribed amount. The resident subsequently developed shortness of breath and was transferred to the hospital, where she was diagnosed with pneumonia. The facility's documentation and staff interviews acknowledged that the administration of excess IV fluids constituted a medication error. The facility's policy required medications to be administered in accordance with written physician orders, which was not followed in this instance.