Medication Omission Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 28 medication administration opportunities and two medication omission errors, resulting in a 7% error rate. The deficiency involved one resident who had been admitted with diagnoses including type 2 diabetes mellitus, hypothyroidism, and hypertension. Physician orders for this resident included Synthroid 50 mcg once daily and glipizide 10 mg every morning. During a morning medication pass, an RN was observed attempting to administer the resident’s medications and was unable to locate the ordered Synthroid in the medication cart or emergency box, resulting in a missed dose. During the same observation, the RN pulled the resident’s glipizide card from the medication drawer but did not remove the scheduled dose before returning the card to the drawer. Before the RN administered the morning medications, the surveyor intervened and questioned whether the glipizide dose had been removed, at which point the RN confirmed it had not and then retrieved the medication for administration. In subsequent interviews, the RN confirmed that Synthroid was not available for administration and that glipizide was only given after the surveyor’s intervention. The DON acknowledged that these two omission errors for Synthroid and glipizide, out of 28 opportunities, resulted in a 7% medication error rate for the observed medication pass.
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