Medication Transcription Error Leading to Significant Metoprolol Overdose
Penalty
Summary
The deficiency involves a failure to ensure a resident was free from significant medication errors when a hospital discharge order for metoprolol tartrate was incorrectly transcribed into the facility’s medication administration record (MAR). The hospital discharge orders directed metoprolol tartrate 25 mg, 0.5 tablet twice a day, but the facility’s physician orders and MAR listed metoprolol tartrate 25 mg, 1 tablet twice a day. As a result of this transcription error, the resident received double the ordered dose of metoprolol for four administrations: the evening of 12/31/25, the morning and evening of 1/1/26, and the morning of 1/2/26. The resident’s diagnoses included heart disease, obesity, heart failure, and atrial fibrillation. During therapy on 1/2/26, the resident became short of breath, and vital signs showed hypotension with a blood pressure of 86/48 mm Hg and bradycardia with a pulse of 42 BPM. EMS was called, and the resident was transported to the hospital emergency department, where the hospital kept the resident for observation. In interviews, an RN confirmed that the metoprolol order from the hospital discharge paperwork had been entered incorrectly into the facility’s MAR, resulting in the resident receiving twice the ordered dose. Staff also reported that an admission checklist existed which included verification of physician orders and medications by two nurses, but this checklist was not required to be completed and was not part of the resident’s record. The facility’s transcribing orders policy stated that physician orders must be transcribed timely, completely, and accurately, and that great care must be taken to ensure accuracy and completeness when transcribing orders.
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