Medication Error Rate Exceeded Due to Improper Crushing and Omitted Doses
Penalty
Summary
A medication error rate of 8.82% was identified during a medication pass observation involving one resident with COPD, benign prostatic hyperplasia, and age-related bilateral cataracts. The resident had an active order for Oxybutynin Chloride XL 5 mg, an extended-release tablet to be given once daily with instructions not to crush. During the observed medication pass, the medication aide crushed the Oxybutynin along with other medications, stating the resident preferred medications crushed. She administered the crushed medications, including the extended-release Oxybutynin, with water. In a subsequent interview, the medication aide acknowledged she had not noticed the "do not crush" instruction in the electronic order and stated she did not know why Oxybutynin could not be crushed. The nurse practitioner and pharmacist both confirmed that extended-release Oxybutynin should not be crushed because it is designed to release medication over 24 hours and crushing would release the dose at one time. The same resident also had active orders for Refresh Tears ophthalmic solution to be instilled in both eyes three times daily and for Fluticasone-Salmeterol inhalation aerosol to be administered twice daily for COPD. During the same medication pass observation, the medication aide did not administer the ordered eye drops or inhaler. She later stated she did not give these medications because she believed the resident kept them at the bedside and self-administered them. However, when the resident was interviewed, he reported that he did not keep these medications at the bedside and denied self-administering them. The interim DON confirmed there were no physician orders authorizing the resident to self-administer medications and stated he did not know why the medication aide believed the medications were at the bedside. He also stated that the medication aide should have followed the medication administration protocol, including not crushing medications that were ordered not to be crushed.
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