Significant Medication Error: Tenfold Haldol Overdose Due to Verbal Order Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when a nurse administered an incorrect dose of Haldol IM to a resident. The resident had recently been discharged from a hospital stay for hip pain following a fall and was admitted to the facility with diagnoses including Parkinson’s disease, adult failure to thrive, severe protein-calorie malnutrition, benign paroxysmal vertigo, history of falling, depression, and cognitive communication deficit. At hospital discharge, and on admission to the facility, the resident was prescribed multiple psychotropic medications, including clozapine for psychosis related to Parkinson’s disease, clonazepam as needed for anxiety, and Remeron for depression. The resident’s medical history also included recurrent falls, severe malnutrition, and a history of delirium and significant hallucinations. On the day after admission, the resident exhibited escalating aggressive behaviors toward staff, including punching and head-butting nurses and slapping a nurse on the buttocks. Staff attempted non-pharmacological interventions such as redirection, providing activities, offering food and drink, and toileting, but these measures did not reduce the behaviors. Nurse practitioners and nursing staff observed the resident kicking, punching, scratching, and grabbing at staff, and the NP decided to order Haldol 2 mg IM for agitation, fighting, and restlessness. The NP reported that she clearly gave a verbal order for Haldol 2 mg IM to a unit manager nurse and then wrote the order, leaving it at the nurse’s computer for later entry into the medical record. The medication error occurred when the unit manager nurse obtained Haldol from the emergency medication supply and administered 20 mg IM instead of the ordered 2 mg. The nurse stated she could not recall whether the NP had specified the dose and admitted she did not repeat the verbal order back to the NP. She reported that “20 mg” stuck in her mind, took four vials of Haldol 5 mg/mL from the emergency supply, and administered the full 20 mg dose to the resident. After giving the injection, she informed another nurse and the NP that she had administered 20 mg, and no one questioned the dose at that time. The nurse later realized the error while entering the written order into the medical record, recognizing that the ordered dose was 2 mg, not 20 mg. The facility’s DON identified the failure to repeat back the verbal order as a breakdown in the process that contributed to the medication error. The consultant pharmacist and medical director confirmed that the intended dose of 2 mg IM was appropriate for the resident’s acute behaviors and that the resident instead received a significantly higher single dose than ordered.
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