Crushing of Contraindicated Medications Leads to Elevated Medication Error Rate
Penalty
Summary
Surveyors identified a failure to maintain a medication error rate below 5 percent when five errors were found among 26 observed medication administrations, resulting in a 19.23 percent error rate. For one resident with anemia and a G-tube, physician orders directed daily administration of ferrous sulfate 325 mg and sennosides-docusate 8.6-50 mg via G-tube, and tamsulosin 0.4 mg via G-tube for malignant neoplasm of the bladder. During a morning medication pass, a licensed nurse noted a discrepancy between the tamsulosin order and the medication card, which was labeled for bedtime administration, and therefore withheld the tamsulosin pending clarification. The same nurse then crushed and administered the ferrous sulfate and sennosides-docusate via the G-tube, despite later confirmation from facility nursing leadership and the consultant pharmacist that these medications should not have been crushed. For another resident with an order for docusate sodium 100 mg capsules (two capsules once daily for constipation) and trazodone 50 mg twice daily for a psychotic disorder, a licensed nurse crushed the trazodone tablet and both docusate capsules and administered them mixed in pudding. Facility nursing leadership later reported that these medications also should not have been crushed. The facility’s medication administration policy stated that medications should not be crushed when contraindicated on a caution label or in the Prescribers’ Digital Reference, but the observed practice of crushing ferrous sulfate, sennosides-docusate, docusate sodium, and trazodone was inconsistent with this policy and contributed to the elevated medication error rate identified during the survey.
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